1. What symptoms are you currently experiencing? *(CHECK ALL THAT APPLY)

2. Have you been officially diagnosed with fibroids or adenomyosis? *

Yes

No, but I suspect I might have them

3. What are you most hoping to gain from treatment? *

Relief from debilitating menstrual pain

Lighter menstrual bleeding

Improved fibroid-free fertility

Restored confidence or self-image

Renewed freedom to travel or exercise

Clarity and peace of mind

Relief from exquisite pain during intercourse

Boosted energy levels

(CHECK ALL THAT APPLY)

4. How important is it for you to avoid major surgery (hysterectomy/myomectomy)? *

Very important – I’m looking for a nonsurgical option

Somewhat important – I’m open to exploring alternatives

Not important – I’m okay with surgery if needed

5. Do you have a prior imaging report (ultrasound, CT, MRI) that demonstrates the presence of fibroids or adenomyosis? Select YES only if you currently have an imaging report available to send. *

Yes

6. The consultation fee for a clinical specialist to evaluate your specific situation and determine your eligibility for the UAE procedure is $330.40 USD (or $330.40 Bahamian). Would you be able to cover this cost? *

Yes

Full Name *

Phone *

Email *

City / Island *

Country *

YOUR INFORMATION & ANSWERS ARE 100% PRIVATE.

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (242) 818-2342 for assistance. You can reply STOP to unsubscribe at any time.

LET'S BEGIN YOUR HEALING JOURNEY

Please answer a few quick questions so we can determine if our treatment

is the right fit and get you ready for your consultation.