Intake form

Name *

Email address *

What is your age?

What is your gender?

What symptoms are you experiencing?

Please select at least one option.

Painful urination

Frequent urination

Blood in urine

Erectile dysfunction

Do you have a family history of urological or andrological issues?

What medications are you currently taking?

Have you undergone any previous urological or andrological treatments?

What is your primary concern or reason for the visit?

Which service or services are you interested in?

Please select at least one option.

Induratio Penis Plastica (IPP)

Disfunzione Erettile

Eiaculazione Precoce

Infertilità maschile

Tumore del Testicolo

Fimosi

Varicocele

Additional questions or comments

Dottor Benedetti Mattia Urologo Andrologo