New-Patient Form

Solving ED with a Customized Treatment Plan

Have an Appointment at Obsidian?

Save time by filling out our new-patient forms here, and we’ll have everything ready for you when you arrive.

Full Name*
Date of Birth
Social Security Number
Address
Email Address
Message
Home Phone
Cell Phone
Occupation
Employer
Employer's Address
Spouse's Full Name
Spouse's Phone
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Personal Physician
Referred By
Agreements
- I understand that Obsidian Men’s Health does NOT accept insurance and that I am liable for all charges, and I agree to pay in full at the time of service.
- I understand that 24 hours’ notice is required to cancel my appointment. (If no notice is given, you will be charged a fee based on the nature of your scheduled visit.)
- I agree to the terms of use.

Give us a call at 703-940-5815, or request a consultation today.

Have more questions about ED and Obsidian’s approach? Take a look at our Erectile Dysfunction FAQ.