Appointment Assistance - Association for the Bladder Exstrophy Community

Establishing care with a new provider is sometimes a lengthy process. If you’re experiencing delays, our A-BE-C team may be able to help you get an appointment. For assistance, complete the form below.

Adult Provider Appointment Assistance

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Name of Requested Provider
Preferred method of contact (from provider's office)*
- Select All
- Phone
- Email
Primary Diagnosis (e.g. BE, CE, EPI)
Summary of Major Surgeries and Bladder Management
Current Problem/Concern
Additional Comments