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 Herman & Wallace Course ISSWSH Other Conference Amazon Google Social Media Other

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

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

Do you typically recommend a specific brand of vaginal dilators/trainers? Which brand and why?

*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

*Email Address

What else should we know about you and your practice?

Website

Submit My Sample Request.