Understanding Fibroids

Understanding Fibroids

CBWW is funded by grants and by providing the information below, you help us to continue to receive grant funding. Thank you for your support.
Name

First NameLast Name
Are you currently or have you been a client of CBWW?
Date of Birth

MonthDayYear
Date
Email
example@example.com
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Which ONE racial classification do you identify with most?
Are you a parent?
If yes, what language do you speak at home?
Are you of Hispanic, Latino/a, or Spanish origin?
Do you speak a language other than English at home?
How well do you speak English?
What is the highest grade or level of school that you have completed?
How much more knowledgeable do you feel about today's subject after this workshop?

1

2

3

4

5

1 is Not at all , 5 is Very knowledgeable
Please list any questions you may have at this time for Dr. Lipman about fibroids.
Please select any barriers you face when managing your fibroids.

Other
Let us know if you are interested in any of the below CBWW services.
Should be Empty: