Sexual Health Intake | Lavena Health

Step 1 of 6

Patient Information

Please complete all fields accurately. This information is used to coordinate your sexual health care.

Personal Details

First Name *

Last Name *

Date of Birth *

Biological Sex *

State *

Email *

Phone *

Street Address *

City *

ZIP Code *

Height

Weight (lbs)

BMI (auto)

How did you hear about us?

If referred by someone, please share their name (optional)

Step 3 of 6

Medical History

Cardiovascular and medication history is critical. Combining PDE5 inhibitors (like sildenafil or tadalafil) with nitrates can cause life-threatening low blood pressure. We screen carefully before prescribing.

⚠ Critical Safety Question

Are you currently taking any of these medications? *

Nitroglycerin, isosorbide dinitrate, isosorbide mononitrate, amyl nitrite ("poppers"), nitric oxide donors, or riociguat (Adempas). Also any recreational use of amyl or butyl nitrite inhalants.

Cardiovascular & Circulatory History

Select all that apply.

Heart attack or coronary artery diseasePast or present

Stroke or TIA

Heart failure or arrhythmia

High blood pressure (uncontrolled)BP often >140/90 despite medication

Low blood pressure (symptomatic)Dizziness when standing, fainting episodes

None of the above

Sexual Health & Urological History

Priapism — erection lasting more than 4 hoursPast or current

Peyronie's disease or penile curvature

Sickle cell disease or bleeding disorder

Retinitis pigmentosa or NAIONHistory of non-arteritic anterior ischemic optic neuropathy

Active prostate cancerMale patients

Active hormone-sensitive cancere.g. active breast cancer

None of the above

Other Conditions, Reproductive Status & Allergies

Diabetes / Insulin resistance

Depression, anxiety, or PTSD

Kidney or liver disease

Low testosterone (known or suspected)Male patients

None of the above

Currently pregnant or breastfeeding? Female patients

Drug allergies (include reaction)

Prior surgeries past 5 years

Step 4 of 6

Treatments of Interest

Your physician will review and recommend what's most appropriate for your situation. Selecting below just tells them what you've heard about or prefer.

PDE5 Inhibitors — Erectile Support

Phosphodiesterase-5 inhibitors relax blood vessels and enhance response to sexual stimulation. Most effective for erectile dysfunction. Generally well-tolerated but require cardiovascular screening and cannot be combined with nitrates.

Oral · On-demand

Sildenafil (generic Viagra)

25–100mg taken 30–60 minutes before sexual activity. Effect lasts 4–6 hours. Best on an empty stomach.

Oral · On-demand

Tadalafil (generic Cialis) — As Needed

10–20mg taken 30 minutes before sexual activity. Effect lasts up to 36 hours ("weekender"). Less food-sensitive than sildenafil.

Oral · Daily

Tadalafil — Low-Dose Daily

2.5–5mg daily. Spontaneous readiness any time. Also approved for benign prostatic hyperplasia (BPH) symptoms.

PT-141 / Bremelanotide — Arousal

Melanocortin-receptor peptide that enhances sexual desire and arousal centrally (in the brain). FDA-approved as Vyleesi for premenopausal women with hypoactive sexual desire disorder (HSDD); used off-label in men. Administered subcutaneously or intranasally.

Subcutaneous Injection

PT-141 / Bremelanotide — SubQ

1.75mg injected 45 minutes before sexual activity. Duration 6–8 hours. Compounded formulation at direct-pay pricing.

Intranasal Spray

PT-141 — Nasal Spray

Compounded intranasal formulation for patients who prefer to avoid injections. Onset slightly slower than SubQ.

Hormone Precursors — Libido & Vitality

Oral hormone precursors used off-label to support libido, mood, and energy. Compounded formulations — not FDA-approved for these indications. Dosing is individualized.

Oral · Daily

Pregnenolone

Precursor to adrenal and sex hormones. Used for low libido, fatigue, mood, and cognitive support. Typical starting dose 25–100mg daily.

Oral · Daily

DHEA

Adrenal androgen precursor. Used for low libido (especially in post-menopausal women), fatigue, and adrenal support. Typical dose 25–50mg daily.

Prior Treatments Tried

Have you tried any sexual-health medications before?

Any additional context or preferences for your physician? Optional

Current Medications & Supplements

All current prescription medications (name, dose, frequency)

Current supplements & vitamins

Step 6 of 6

Informed Consent & Signature

Please read carefully. Your electronic signature is legally binding under Florida Statute §668.50.

Informed Consent for Sexual Health Treatment

Nature of Treatment

I am consenting to receive sexual health treatment prescribed by a licensed Florida physician through Lavena Health. Depending on my evaluation and needs, my physician may prescribe phosphodiesterase-5 (PDE5) inhibitors such as sildenafil or tadalafil, the melanocortin-receptor peptide PT-141 (bremelanotide), and/or hormone precursors such as pregnenolone or DHEA. Administration may be oral, subcutaneous injection, or intranasal, as clinically indicated.

Off-Label & Compounded Disclosure

I understand that: (a) sildenafil and tadalafil are FDA-approved for men with erectile dysfunction but are used off-label in women; (b) PT-141 / bremelanotide is FDA-approved (as Vyleesi) for hypoactive sexual desire disorder in premenopausal women and is used off-label in men; (c) compounded PT-141, pregnenolone, and DHEA are prepared by licensed compounding pharmacies and have not undergone FDA pre-market review; (d) pregnenolone and DHEA are not FDA-approved for libido or sexual function indications. I accept this as part of my informed decision.

Potential Benefits

Improved erectile function and sexual performance (PDE5 inhibitors)
Enhanced sexual desire and arousal (PT-141)
Improved libido, mood, energy, and hormonal balance (pregnenolone, DHEA)
Improved relationship satisfaction and self-confidence
Spontaneous readiness with daily low-dose tadalafil

Individual results vary. Response to treatment depends on underlying cause, hormonal status, psychological factors, and overall cardiovascular health.

Risks, Side Effects & Critical Warnings

Absolute contraindication (PDE5 inhibitors): Concurrent use with ANY nitrate medication (nitroglycerin, isosorbide, amyl nitrite / "poppers") or the pulmonary hypertension drug riociguat can cause severe, life-threatening drops in blood pressure. Never combine these medications.

Priapism emergency: If I experience an erection lasting 4 hours or longer, I will seek emergency medical care immediately. Untreated priapism can cause permanent erectile dysfunction.

Headache, facial flushing, nasal congestion, dyspepsia — common with PDE5 inhibitors
Back pain or myalgia — more common with tadalafil
Rare vision changes (blue tint, NAION) or sudden hearing loss — discontinue and seek care
Nausea, flushing, transient blood-pressure elevation — with PT-141 (typically resolves in 1–2 hours)
Focal hyperpigmentation — reported with repeated PT-141 use
Androgenic side effects (acne, hair changes) — possible with DHEA
Hormonal shifts with pregnenolone/DHEA may affect estrogen/testosterone levels and are not recommended during active hormone-sensitive cancer
Unknown long-term safety profile for compounded pregnenolone and DHEA in sexual health indications
Rare allergic reaction — discontinue and seek care if rash, swelling, or difficulty breathing occurs

Patient Responsibilities

I will not combine any PDE5 inhibitor with nitrates, amyl nitrite ("poppers"), or riociguat — even recreationally
I will seek emergency care immediately for any erection lasting 4 hours or longer
I will report any adverse reactions, new cardiovascular symptoms, or vision/hearing changes to my provider promptly
I will inform my physician of any new prescriptions before starting them
I will complete baseline and follow-up labs if requested (hormones, metabolic panel, PSA for men)
I will store all medications as directed and use sterile technique for any injectable treatment

Direct-Pay & Truthfulness

I certify that all information in this intake is truthful and complete to the best of my knowledge, including disclosure of cardiovascular conditions, nitrate use, and other medications. I understand that Lavena Health is a cash-pay clinic and no insurance is billed. Transparent pricing will be discussed before any prescription is issued. I may withdraw consent at any time without affecting my access to other services.

Identity Verification

Why we ask: Florida law and federal telehealth regulations require that prescribing physicians verify patient identity before issuing prescriptions. Your attestation below satisfies this requirement for your initial intake. A government-issued photo ID may be requested at or before your first consultation.

I attest that I am the person named in this intake form and that all personal information provided (name, date of birth, address) is accurate and truthful.

I understand that a valid government-issued photo ID (driver's license, passport, or state ID) may be requested before my prescription is issued, and I agree to provide one upon request.

I confirm that I am a resident of the state selected in this form and am physically located within that state at the time of this consultation request.

Date of Birth (re-enter to confirm identity)

Acknowledgments & Signature

I have read and understood the nature, risks, and benefits of the sexual health treatments described above, including the off-label and compounded status of certain medications.

I understand that PDE5 inhibitors (sildenafil, tadalafil) must never be combined with nitrates, amyl nitrite ("poppers"), or riociguat, and I will not do so. I have accurately disclosed any nitrate use in this intake.

I understand that any erection lasting 4 hours or longer (priapism) is a medical emergency. I will seek emergency care immediately if this occurs.

I confirm I am 18 years of age or older, am the patient named in this form, and voluntarily consent to sexual health treatment through Lavena Health. All information provided is truthful and complete.

Full Legal Name *

Or type your full legal name as your electronic signature

Today's Date *

Electronic Signature Notice: By typing your full legal name above and clicking Submit, you are providing a legally binding electronic signature under Florida Statute §668.50 and the federal E-SIGN Act (15 U.S.C. § 7001). This constitutes your informed consent to sexual health treatment through Lavena Health.

ID Verification — Optional but recommended

Upload a photo of your government-issued ID to verify your identity. This helps your physician review your file faster.

📷 Tap to photograph ID or upload a file JPEG, PNG or PDF · Max 6MB · Encrypted & HIPAA secure

Patient Information

Sexual Health Assessment

Medical History

Treatments of Interest

Lab Work & Health Markers

Informed Consent & Signature