Uterine Fibroid Study Questionnaire 
Please complete the form to determine if you will be selected participate in this study
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Email *
First Name *
Last Name *
Mobile phone number (will only be used if selected) *
What is your ethnicity? *
What is your age? *
Have you been medically diagnosed with uterine fibroids in the past 10 years? *
Has your doctor or health care professional recommended surgery to remove fibroids or hysterectomy? *
Have you been a permanent resident of the United States for at least the past 10 years? *
If selected, are you able to participate in a virtual interview for 1-1 1/2 hours? *
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