If you would like to be notified when we launch the Bladder Health Mobile, and would like it to visit your community, please fill out the following form.  Please check-off any way(s) you can participate in the project with the exhibit arrives in your community.

Volunteer to co-chair the local Bladder Health Mobile Host Committee

Be a media expert on the following aspects of bladder health:
          Incontinence
          Bladder Cancer
          Interstitial Cystitis
          Prevention and Good Bladder Habits
          Urinary Tract Infections

Answer patient questions at the exhibit

Organize patient education seminars to coincide with the Bladder Health Mobile's visit to my community

Facilitate the exhibit visiting my hospital or clinic

Name:

Organization:

Address:

City:

State:      Zip:      Phone:

E-Mail:

Any Additional Comments or Questions: