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Home >> Get Involved >> Continence Competition

Continence Competition

All completed Information Request forms go into our monthly draw to win one of Dr Rosie King's 'Pelvic Floor Work Out' audio tapes.

To enter, simply fill out the form below and submit it to us! It couldn't be easier!

In an effort to continue to offer up-to-date and relevant information, we are constantly seeking the help of those who experience bladder and bowel problems.

If you experience these problems, please take a few seconds to fill out this confidential form, and help us.... to help you!

Remember, your submission enters you into our weekly draw to win one of Dr Rosie King's 'Pelvic Floor Work Out' audio tapes. Winners will be notified by their supplied E-mail.

Fields marked (*) are compulsory

* Full Name:
* E-mail: (e.g.yourname@domain.co.nz)
Postal Address:
(So that we can send information to you by post)
* City:
Age:
Gender:
Ethnic Group:
Problems related to:
Estimated duration of suffering:
Sought previous medical attention:
Require further assistance:
 

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