PAE Consultation Request

Request a PAE Consultation

Name(Required)

Phone(Required)

Email(Required)

Insurance(Required)

Have you ever been diagnosed with Benign Prostatic Hyperplasia (BPH)?(Required)

Symptoms (Select All That Apply)(Required)

Frequent urination

Waking up in the middle of the night to urinate

Difficulty starting urination

Weak urine stream

Inability to completely empty the bladder

None of the above

Are you willing to travel to Fort Worth?(Required)

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