O'shot Orgasm Shot

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* 1. Please choose one, or more, of the following that best describes your issue with vaginal and sexual health

Pain during intercourse or loss of sexual pleasure

Urinary Incontinence

vaginal dryness

Changes in the appearance or color

Chronic unusual bleeding or discharge

Loss of Sexual Pleasure

Not Able to reach Orgasm

Please use this box if you chose "Other" or if you wish to explain your condition in more details

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* 2. When did start noticing these symptoms

After giving birth

After hysterectomy

After Chemotherapy?

After menopause

Other (please specify)

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* 3. How long have you had these symptoms for?

Less than one year

between one to two years

More than two years

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* 4. Have you tried any of the of the following treatments

Hormone Replacement Therapy Tablets

No treatment at all

Education and behavioral interventions

Vaginal Creams

Other (please specify)

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* 5. Have you heard about O'shot before?

Yes

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* 6. what is your personal perception of O'shot Vaginal treatment safety and efficacy?

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* 7. Please rate the impact of these vaginal symptoms on your life in general

insignificant

Moderate

devastating

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 8. What would be a reasonable price for this O'shot knowing it will be safe and effective?

1000

1500

2000

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 9. please provide your contact information, so we can arrange for a free consultation and to get the $100 coupon.

First Name

Last name

Email Address

Phone Number

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* 10. How do you like us to contact you

Phone call

email address

Text message