Confirmation Page - Peyronies Disease Institute

Name*

First Last

Email*

Customer statement of physician consent*

By checking this box I certify that I am of legal age to make decisions about my healthcare. I have discussed the use of non-traditional nutritional and other alternative treatment of Peyronie’s disease with my treating physician. I am using ideas or products found on this website and store front with the consent of said medical doctor who is treating my Peyronie's disease. I fully acknowledge and bear sole responsibility for any and all reactions that I may have, physical and otherwise, as a result of the use of products and or treatment alternatives discussed in this website. Further, I certify that I am the user of these products being order, or an authorized agent of the user who guarantees that the user is in agreement and compliant with all terms of this certification statement.