Personal Details Title select Dr. Mast. Miss Mr. Mrs. Ms. Pris. Prof. Rev. Initials First Name Last Name Company Specialty select Ambulance Services - Advanced Ambulance Services - Basic Ambulance Services - Intermediate Anaesthetic Approved U O T U / Day Clinics Biokinetic Cardio Thoracic Surgery Cardiology Chiropractor Clinical Haemotology Clinical Technology Dental Therapist Dentist Dermatology Diagnostic Radiology Dietician Drug & Alcohol Rehab Emergency Medicine Specialist ENT Specialist Gastroenterology General Practitioner Hearing Aid Acoustician Homeopath Hospices Medical Oncology Medical Technology Neurologist Neurology Neurosurgery Nuclear Medicine Nursing Agencies/Home Care Services Obstetrics & Gynaecology Occupational Medicine Independant Specialist Occupational Therapy Ophthalmology Optometry Orthopaedic Orthoptist Orthotist & Prosthetist Osteopathy Other Paed Cardiology Paediatry Pathology Pharmacist Physical Medicine Physiotherapist Phytotherapy Plastic & Reconstructive Surgery Podiatry1 Psychiatrist Psychiatry Psychologist Psychometry Pulmonology Radiation Oncology Radiography Registered Councellor Registered Nurse Rheumatology Social Worker Specialist Family Medicine Specialist Medicine Speech Therapy & Audiology Surgery/Paediatric Surgery Therapeutic Reflexologist Travel Clinic Unattached Operating Theatres / Day Clinics Urologist Urology Specify other Contact Details Phone Cell Fax Primary Email Confirm Email Address Details Country select Afghanistan Akrotiri Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ashmore and Cartier Islands Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Bassas da India Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Cook Islands Coral Sea Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Dhekelia Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Europa Island Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia, The Gaza Strip Georgia Germany Ghana Gibraltar Glorioso Islands Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Jan Mayen Japan Jersey Jordan Juan de Nova Island Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova Monaco Mongolia Montserrat Morocco Mozambique Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paracel Islands Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tromelin Island Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands Wake Island Wallis and Futuna West Bank Western Sahara Yemen Zambia Zimbabwe City Address Line 1 Address Line 2 Zip/Post Code Council Registration No. / Student No.*** Academic and Professional Qualifications Add   Id Sorted desc Year Institution Qualification   1 Page size: select 5 10 20 50  0 items in 1 pages No records to display. Relevant related work experience (brief) and current position Add   Id Sorted desc Date Employer Position   1 Page size: select 5 10 20 50  0 items in 1 pages No records to display.

Please tick your areas of specialisation and / or interest (e.g. if you have no experience in treating Erectile dysfunction but that you are interested in working with it in the near future, please tick the interest column).

ITEM EXPERIENCE INTEREST Erectile Dysfunction (Medical examination and prescription of medication) Erectile Dysfunction (Psychological treatment) Erectile Dysfunction (Injectable treatments) Erectile Dysfunction (Surgical implants) Penile Enlargement Surgery Sexual Desire Disorders (Men) Sexual Desire Disorders (Women) Arousal Disorders (Women) Orgasmic Disorders (Women) Ejaculation / Orgasmic Disorders (Men) Intercourse Difficulties in Women (Pain, discomfort, fear) Intercourse difficulties in men due to lower UTI’s Sexual Sequelae of Child Sexual Abuse in Adults Sexual Abuse (Children and Adolescents) Rape and Sexual Assault (Counselling) Rape and Sexual Assault (Medical Examination) Sexual Orientation Issues Gender Identity Disorders Nonparaphilic Compulsive Sexual Behaviours Paraphilic Compulsive Sexual Behaviours Urological Problems Affecting Sexual Function Sexually Transmitted Infections HIV/AIDS Testing HIV/AIDS Treatment HIV/AIDS Counselling Sperm Washing for HIV/AIDS Fertility Problems Relationship therapy / counselling Relationship Enrichment, education & training Sexuality & Religion / Spirituality Childhood Sexuality Education Pre-Adolescent Sexuality Education Young Adult Sexuality Education Safer Sex Education HIV/AIDS prevention – education & training Sexuality in the media

Please list any other relevant conditions that you treat which are not listed above: Add   Id Sorted desc Notes   1 Page size: select 5 10 20 50  0 items in 1 pages No records to display.