PHN Samples Request Form

* My PRIMARY Occupation is...
Student Physical Therapist Occupational Therapist Nurse, NP, or CNM Doctor Educator Other

* How long have you been aware of Intimate Rose products?
0-3 months 4-6 months 6-12 months 1 Year or more

* Where did you FIRST hear about Intimate Rose?
APTA CSM APTA Menopause Course APTA Pelvic Health Level 1 APTA Pelvic Health Level 2 Evidence in Motion Herman & Wallace Course ISSWSH Other Conference Amazon Google Social Media Other

* Tell us about the sex of your patient population:
Mostly Female Mostly Male About half and half

* How often do you see a patient before or after gender affirmation surgery?
Never Rarely Occasionally Often

* In an average month, how many NEW patients with URINARY INCONTINENCE do you see?
0 1-2 3-6 7-10 10-15 16+

* In an average month, how often do you recommend pelvic floor weights (vaginal weights) to your patients:
I've never recommended vaginal weights 0-1 2-4 5-8 9+

* In an average month, how many NEW patients with PELVIC PAIN do you see?
0 1-2 3-6 7-10 10-15 16+

* In An Average month, How Many NEW Patients with Interstitial Cystitis (IC) or Painful Bladder Syndrome (PBS) do you see?
I do not see patients with IC or PBS 0-1 2-4 5-8 9+

How many patients with hormone driven headaches, or painful periods do you see?
I do not see patients with hormone driven headaches or painful periods 0-1 2-4 5-8 9+

* In an average month, how many times do you recommend Dilators for Vaginal Use to a patient?
I've never recommended dilators 0-1 2-4 5-8 9+

* In an average month, how many times do you recommend Dilators for Rectal Use to a Patient
I've never recommended rectal dilators 0-1 2-4 5-8 9+

* In an average month, how many times do you recommend a Pelvic Trigger Point Wand to a patient?
I've never recommended pelvic trigger point wands 0-1 2-4 5-8 9+

* In average month, how many times do you recommend a vulvar balm (or coconut oil) for vulvar dryness and irritation?
I've never recommended vulvar balms 0-1 2-4 5-8 9+

* If you like our products, would you be interested in selling Intimate Rose products in your clinic?
yes no

Sometimes when shipping to hospitals or clinics, our samples get lost in their mail system. Please confirm the address below at which you can receive shipments:

* Clinic / Hospital Name

* First Name

* Last Name

* Phone Number

* Address

Apartment/Suite Number

* City

* State

* Zip

* Country

* Email Address

Social Media Handles

What else should we know about you and your practice?

Would your clinic be interested in a 30 minute presentation to learn more about our products?

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