Pelvic Floor Appointment Request Form
If you're interested in scheduling an appointment or would like more information about The Christ Hospital Pelvic Floor Center, please complete the form below and a member of our team will contact you.
First Name
*
Last Name
*
Phone
*
Email Address
*
Preferred Method of Contact
*
Phone
Email
Phone or Email
Preferred Time of Contact
*
Morning
Afternoon
Are you currently experiencing any of these symptoms? Please select all that apply.
*
Accidental bowel leakage
Bladder emptying problems
Bladder pain
Bowel emptying problems
Complications of previous surgery
Frequent or urgent urination
Painful intercourse
Pelvic pain
Problems with the vulva
Rectal prolapse
Recurrent bladder infections
Urinary leakage
Vaginal bulging
Other
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Billboard
Event
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Family or friend recommendation
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Physician recommendation
Poster display
Radio
The Christ Hospital website
Website ad
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MAIN CAMPUS
2139 Auburn Avenue
Cincinnati, OH 45219
513-585-2000
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