Uterine Fibroid Embolization Contact Form
Thank you for participating in the Uterine Fibroid Outreach Project. This form helps us understand your needs and provide you with the most relevant resources and support.
1.
First Name
2.
Last Name
3.
Email Address
4.
Phone Number
5.
Preferred Contact Method
Phone
Email
Text Message
6.
City & State
7.
If you attended an event where you were presented with this form, please indicate the event or program location:
Atlanta, GA
Chicago, IL
Newark, NJ
Philadelphia, PA
Washington, DC
Other
If other (please specify):
8.
How did you hear about this outreach event/program?
Social Media
Community Event
Friend/Family
Other
If other (please specify)
9.
Additional Comments or Questions:
