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* 1. Please choose one, or more, of the following that best describes your issue with vaginal and sexual health

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* 2. When did start noticing these symptoms

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* 3. How long have you had these symptoms for?

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* 4. Have you been diagnosed with bladder prolapse?

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* 5. Have you tried any of the of the following treatments

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* 6. Have you heard about Vaginal Laser treatment?

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* 8. Please rate the impact of these vaginal symptoms on your life in general

insignificant Moderate devastating
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 9. please provide your contact information, so we can arrange your consultation

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* 10. How do you like us to contact you

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