Sample Form

Contact form

Doctor's Information

Full Name:

Medical License Number:

Specialty:

Clinic/Hospital Name:

Clinic/Hospital Address:

Street: City:

State: Zip Code: Zip Code:

Phone Number:

Email Address:

Sample Request Details

Number of Patients Expected to Benefit:

Dilator Sizes Requested (Check all that apply): Small Medium Large Full Set

Purpose of Request (Check one): Patient Education Post-Surgical Rehabilitation Pain Management (e.g., vaginismus, dyspareunia) Others:

Acknowledgment

By submitting this form, I confirm that I am a licensed healthcare provider and that these samples will be used solely for patient care or educational purposes.

Signature:

Date:

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Contact form

Doctor's Information

Sample Request Details

Acknowledgment