Get TriMix Here

How To Get Treatment

If you would like to schedule a telemedicine appointment to be evaluated for trimix, the questionnaire needs to be completed and submitted. You will be contacted within 24 hours to schedule your appointment. Telemedicine evaluation will take about 15 minutes. You will be charged $75 for the telemedicine appointment at the time of booking. The telemedicine fee is a fee for the physician’s time and expertise and is a completely separate and independent charge from the medication.

Simply fill out the questionnaire below, electronically sign it, and our medical experts will craft the perfix Trimix solution just for you!

Name:

Date:

E-Mail:

Date of Birth:

Street Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Sex:

Height:

Weight:

Emergency Contact Name:

Emergency Contact Relationship:

Emergency Contact Phone:

Do you have any special needs?:

What are your health concerns?:

Who is your primary care provider?:

Primary care provider address:

Primary Care Provider Phone:

Please list any allergies you might have:

Please list any medications you are currently taking:

Please list any supplements you are currently taking:

List hospitalizations or surgeries you have had with corresponding dates:

Have you been diagnosed with any diseases or disorders and if so, when?:

Any prior or current diagnosis of cancer?:

Any prior or current diagnosis of type 1 diabetes?:

Any prior or current kidney disease?:

Any prior or current liver disease?:

Any surgery within the last four (4) weeks?:

Any surgery scheduled in the next three (3) months?:

Date of most recent full physical exam:

Any abnormalities noted?:

Date of most recent blood work:

Any abnormalities noted?:

Are there any additional health concerns or questions you have?:

I hereby authorize "Perfect Health Technologies, Inc. Physician contracted by Perfect Health Technologies to use the following to facilitate and prescribe Trimix.

I recognize the potential risks and benefits of these procedures as described below:

A small amount of medication is injected by a very tiny needle into the side of the penis.

As you probably know an erection occurs because the penis fills with blood and it becomes distended. This medication helps to increase the blood flow to the penis. Each time you desire an erection, and injection is required. It creates a very natural looking and feeling erection.

This method of improving erections has been popular for over ten years. It has been our observation that this method of creating an erection has very few complications. The main complication is that the erection may not go down in the appropriate amount of time (this occurs in less than 5% of the cases) – If this problem is going to occur, it usually happens the first or second time of use.

Each person reacts little differently to the medication. Therefore, we usually prescribe only 1/2 the normal amount of medication the first time you use it to see how you react. If you would happen to have an erection that lasts more than 4-6 hours, you would need to seek medical attention to get an antidote. Another complication that may occur after prolonged use (over years) is the development of scar tissue in the penis. (Again, this is a relatively uncommon problem.)

There are currently three kinds of medication available. All of these medications work the same way by increasing the blood flow to the penis.

A combination of all three medications is now available by special Compounding It is called TriMix. I have been very impressed by its effectiveness, minimal complications and its relative low cost. It is very easy to learn to give yourself and injection in a short period of time.

Enclosed in the information are diagrams and instructions about the injections and how to give them.

I understand that a record will be kept of the health services provided to me. This record will be kept confidential, and will not be released to others unless so directed by myself, my representative, or unless law requires. I understand that I may look at my medical record and can request a copy of my record by my paying the appropriate fee. I understand that my medical record will be kept no more than ten years after the date of my last treatment. I understand that the doctor will answer any questions that I might have.

With this knowledge, I voluntarily consent to the above procedures. I realize that neither the doctor nor any personnel of Perfect Health Technologies has made any absolute guarantees to me regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and discontinue participation in these procedures at any time. I waive my right to future litigation regarding my present health condition by signing this agreement.

I, (patient name) hereby authorize Perfect Health Technologies / Diet Doc Weight Loss to communicate with me via email.

(electronically sign).