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

How long have these symptoms been affecting your life? *

Less than 6 months

6 months – 1 year

1–3 years

Over 3 years

Have you been officially diagnosed with fibroids or adenomyosis? *

Yes

No, but I suspect I might have them

What are you most hoping to gain from treatment? *(CHECK ALL THAT APPLY)

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

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

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 *

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.