Do you occasionally dribble or leak when you sneeze, cough or exercise?YesNo

Do you feel urinary urgency (feeling that you have to go to the bathroom)?YesNo

Are you being treated for incontinence with medications or pelvic floor therapy?YesNo

Are you currently being treated with hormones/estrogen?YesNo

Do you feel loose vaginally since childbirth or menopause?YesNo

Do you feel dry during intercourse? Have trouble reaching orgasm?YesNo

Have your intimate relationships suffered due to any of the above?YesNo

If there was an in office, non-surgical treatment solution that is painless, with no downtime that could help with many of these issues would you be interested?
YesNo

If over 90% of women suffering from laxity, dryness, incontinence, and sexual dysfunction found this treatment to be effective and worth the cost would you consider speaking with the doctor about this treatment?

YesNo

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