Patient Registration Form | Priapus Surgery

Patient Registration – Personal Data

Please fill out the following information accurately. All data is kept confidential and used only for your medical evaluation and surgical planning.

Patient Registration – Personal Data

Name:

Last Name:

Phone Number:

Mobile

Preferred Method of Contact

City

State

Registered Email Address

Date of Birth

Age

Height

Weight

Education

Occupation

Do you consume alcohol?

Do You Smoke?

Do you use narcotics or recreational drugs?

If yes, please specify which narcotics or drugs you use:

What are your sexual preferences, by percentage (%)?

What are your sexual preferences?

Do you have any medication allergies?

Are you allergic to latex?

Have you ever received a blood transfusion?

Previous Surgeries:

Do you currently have or have you ever had any disease?

Prescriptoin Medications

Vitamins

Weight Loss Products

What concerns or symptoms do you have regarding your genital area?

What are your expectations or goals for the surgery?

Preferred or Expected Surgery Date:

What is your estimated budget for the surgery?

What is your planned method of payment for the surgery?

Please select the procedure(s) you are interested in:

Free Text

📸 Picture Submission Instructions for Surgical Evaluation

To properly assess your case, please follow the guidelines below when submitting your photos and video. High-quality images are essential for an accurate evaluation and treatment plan.

🔹 Required Photo Projections (Good Lighting, Patient Standing):

Frontal View – Flaccid

Frontal View – Erect

Left Side View – Flaccid

Right Side View – Flaccid

Photos must clearly show the pubic area and its transition to the lower abdomen. In patients with overweight or excess tissue, using a selfie stick may be necessary to ensure full visibility.

🎥 Optional Video Submission (Highly Recommended):

We encourage you to send a short video (1–2 minutes) explaining:

What bothers you most about the aesthetics of your genital area

Any visible scarring, irregularities, or previous surgical changes

Ensure that any abnormalities or concerns are clearly visible in the video or photo set.

Picture 1

Upload File

Picture 2

Upload File

Picture 3

Upload File

Patient Registration – Personal Data

Penis Enlargement Surgery

Email