​Bocox™ Erectile Dysfunction & Botulinum Toxin Type A Online Consult

This is a validated questionnaire to help identify men who have a problem with Erectile Dysfunction.
Please select the response that best represents your answer for each of the questions below. While your experiences may change from time to time, what we need to know is your general experience with intercourse.

These Online Tests are simple questionnaires that are submitted to our doctors to see if Essential Men's Clinic has a solution that is right for you. They are obligation free and absolutely confidential. 

​Please note that by submitting this form you will be signed up to the Essential Mens Clinic Newsletter. We respect your privacy and you can unsubscribe at anytime.

Our Doctors will to your submission from your given email address.
Your personal details will remain confidential and not disclosed to any third parties.
You have the right to view, change or delete this information on request.
This questionnaire is not comprehensive, and does not replace a full history and physical examination and further information may be necessary on follow-up.
​Due diligence will be exercised for making a thorough assessment.