Are you a candidate for UFE?
Fill out this quick form in 60 Seconds. See if you are a candidate for UFE.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Have you been diagnosed with fibroids?
Yes
No
How were you diagnosed?
Physician Diagnosis
Ultrasound Diagnosis
MRI Diagnosis
Other
What symptoms are you currently experiencing?
Anemia
Heavy Periods
Painful Periods
Back Pain
Pain during/after intercourse
Bloating/Constipation
Frequent Bathroom Trips
Other
When was your last well woman exam?
1 - 3 Years
3 - 5 Years
5+ Years
I cant remember
Select your insurance
Please Select
AARP
Affinity
Aetna
Ambetter
Amerigroup
BCBS
Cigna
Community Health Choice
Health First
Health Plus
Humana
Medicaid (Traditional)
Molina
Other
Self Pay
Tricare
UHC Community Plan
United Healthcare
Other
Input Insurance
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