a. Screening 1

Elidah Male SUI Study

Thank you for your interest in participating in our clinical study. Please fill out the form below to see if you are eligible.

Full Name *

Email *

Phone Number *

Date of Birth *

Date of laparoscopic prostatectomy *

If in the past, how many pads/day do you use?

Do you read and speak English?

Select if you have any of the following? *

What is your height in inches? *

60

72

84

What is your weight in pounds? *

What is your BMI? *