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Interstitial Cystitis (IC) Workshop Registration

Please fill out the form below to the best of your ability. Once you submit the form, you will receive an email with a link to pay the $10 workshop registration fee.

First Name*

Last Name*

Email*

Have you been diagnosed with IC?*

Yes

No

Do you suffer from any of the following? Please check all that apply.

Bladder pain

Pelvic pain

Bladder pressure

Urgency & frequency of urination

Painful urination

Leg & back pain

Other

Are you currently a patient at Pelvic Elements?*

Yes

No

I am a former patient

Where did you hear about this workshop?*

Facebook ad

Google search

Social media

Recommended by a family member, friend, doctor, etc.

Other