UCANPOOPTOO Interest Form
Thank you for your interest in future U-CAN-POOP-TOO studies.
The data you provide will not be used for anything other than to contact you about possible new studies.
It will be kept strictly confidential and maintained on our secured server.
  
 
Last Name:
 
First Name:
 
Email Address:
 

Child's Birth Date:

 

How long has encopresis been a problem (in months)?

  

How many accidents has your child had in the last 2 weeks?

  
Have you sought medical help for encopresis in the past?

  

Would you prefer to seek help for encopresis over the Internet or face-to-face with a physician?

  



If we were to charge for this program, how much would you be willing to pay for this type of online program (in dollars)?

  
Other Comments: