PHN Samples Request Form

* indicates required

*My PRIMARY Occupation is...

*How long have you been aware of Intimate Rose products?

*Where did you FIRST hear about Intimate Rose?

*Tell us about the sex of your patient population:

*How often do you see a patient before or after gender affirmation surgery?

*In an average month, how many NEW patients with URINARY INCONTINENCE do you see?

*In an average month, how often do you recommend pelvic floor weights (vaginal weights) to your patients:

*In an average month, how many NEW patients with PELVIC PAIN do you see?

*In An Average month, How Many NEW Patients with Interstitial Cystitis (IC) or Painful Bladder Syndrome (PBS) do you see?

How many patients with hormone driven headaches, or painful periods do you see?

*In an average month, how many times do you recommend Dilators for Vaginal Use to a patient?

*In an average month, how many times do you recommend Dilators for Rectal Use to a Patient

*In an average month, how many times do you recommend a Pelvic Trigger Point Wand to a patient?

*In average month, how many times do you recommend a vulvar balm (or coconut oil) for vulvar dryness and irritation?

*If you like our products, would you be interested in selling Intimate Rose products in your clinic?

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?

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