Name:
Email:
*
Have you been diagnosed with uterine fibroids?
Yes
No
Are you pregnant?
Yes
No
Do you experience heavy or abnormal bleeding during and/or in between periods? Do you have painful or pelvic pressure?
Yes
No
Have you had a pelvic MRI?
Yes
No
Have you had a pelvic Ultrasound?
Yes
No
Phone:
*
Any Other Additional Relevant Information?