New Customer – EDSAustralia

Name*
First Last
Date of Birth*

DD
MM
YYYY
Phone*
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please select your preferred consultation method*
*to obtain a free consult you will need to provide EDSAustralia with a valid General Practitioner referral prior to your consult otherwise we require a fee of $110 up front for a consult with Dr Elmes.
What is your preferred date and time for the consult?
(please note we can not guarantee the time and date you have specified but we will aim to secure the closest possible for you)
Term and Conditions*
- I have read and agree to the EDSAustralia Terms and conditions
To the best of my knowledge, the above information is correct:*
- To the best of my knowledge, the above information is correct:
Term and Conditions*
- If my medical condition changes or any information I have submitted changes I will notify EDSAustrlia by phone or email.
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Helping Men
Regain Confidence In The Bedroom