Pelvic Health Center Intake Form
Dear New Patient,

We are excited to get started on your care. Enclosed you will find several pages of forms, including:

• Patient Agreement: including policies and fees for the practice. Please take your time to read over it.

• Intake Form: This is the place where we learn everything about your condition, your lifestyle, and how this has been affecting you. The more thorough, the better. Your intake will be carefully read twice before your first visit, so we are not asking questions you have already carefully answered. If you are uncomfortable typing and emailing this form, you may mail it to 200 N. La Cumbre Road, Unit K. Santa Barbara, CA 93110. Our email is HIPPAA compliant, but we cannot guarantee that your email is. If you would rather print, fill out, and mail the form, you may.


• Communication form and preferences

** We request you to fill out your intake forms and either email them to or to mail them to our office so they reach us 2 business days before your evaluation date. This gives our pelvic health therapists due time to fully read through your intake in preparation for your visit. **

**If this is not possible for you, you may fill them out at our office. You must come 45 minutes before your appointment if you choose to do so. If you fill out your intake forms at our office, please be aware that your pelvic health therapist will not be fully prepared for your visit.**

Patient Agreement: Pelvic Health Center of Santa Barbara

At Pelvic Health Center of Santa Barbara we are committed to providing you with the best possible pelvic health therapy care. The following policies allow us to provide optimal care for all of our patients.

**Payment is due at the time of service. Cash, Check, or Cards are accepted forms of payment. Rates as of January 1, 2020.**

• For the first evaluation, as well as all follow-up visits, Dhara charges $250 per hour. To ensure a timely start to your appointment, please arrive 10 minutes before the scheduled time. Arriving early will allow us to use all of our time together for your care. Your time is reserved for 55 minutes at the start of your treatment time. If a patient arrives late, they will be charged for the time that was reserved for them. Our pelvic health therapists will not see patients past the 55-minute mark, even if the patient arrived late.

• Prior to your evaluation, you will fill out this paperwork. Your pelvic health therapist will review it once we receive it and then again a day before your visit. At your first visit, your pelvic health therapist will clarify any questions that they had while reading your intake. We will do a very thorough evaluation and spend the remainder of your time on treatment.

• Insurance Forms:
If requested, we will provide you with a super bill with diagnosis codes and billing codes that you can send into your insurance provider for possible reimbursement. We cannot guarantee that your insurance company will refund you any of what you have spent at our office, but many of our patients have had great success with this. Our office will not submit the super bill directly to your insurance company. You may also use an HSA account to pay for your visits.

**Medicare patients:
 You will be required to sign a form (ABN) agreeing not to submit charges to Medicare and requesting that we do not. Because Medicare does not cover the care methods, treatment duration, diagnoses we treat, chronic issues, visceral or neural mobilization, or wellness care, Pelvic Health Center has terminated its Medicare Number and has no reimbursement relationship with Medicare. Please let us know if you would like us to recommend a Medicare provider for you. It is our preference to refer Medicare patients to Medicare approved facilities and providers, so they may utilize their benefits.**
• Potential Benefits:
Most patients are very pleasantly surprised at the rapid resolution of symptoms or their increased function. You may experience improvement in your symptoms, improved mobility, function, or feelings of general physical and emotional health. You may experience improved knowledge of your condition, improved self-management, or decreased pain and dysfunction.

• No Warranty:
Pelvic health therapy is an art and a science of trial and error. No two patients are the same and we cannot guarantee a certain number of visits will produce any certain outcome. Healing is a complex, multifactorial, individualistic response that involves several factors. Pelvic Health Center is but one of the factors in your healing as well as proper diet, exercise, spiritual fitness, mental wellness, healthy relationships, and the rest of your medical team. The patient understands that the pelvic health therapist cannot make any promises or guarantees regarding a cure or improvement of physical conditions. You agree that the therapist will share with you their opinions regarding potential results of pelvic health therapy for your condition and will discuss all treatment options with you. This is a voluntary relationship between two parties. If at any time you are dissatisfied with your care, please let your pelvic health therapist know immediately.

• Potential Risk:
You may have an increase in symptoms as your body accommodates. This is usually temporary and not typically the case. You agree to let your pelvic health therapist know if the treatment is painful as we seek to avoid pain during your session - this communication is essential. You agree to contact your physician or seek emergent care if you have any severe symptoms as Pelvic Health Center is not a primary or emergent care provider.

As a Patient you agree:

1. To have seen a physician for this condition, whom we can send a script to for signatures. If you are coming for wellness care, we still require you to be seen by another primary care provider who can sign a care plan: MD, DO, DC, or ND. We are not able to detect issues such as cancer, tumors, endometriosis, hormonal imbalance, cardiac disease, bony abnormalities/pathology of organic disease processes from physical therapy evaluation. This will fall under the realm of your primary care.

2. You agree to come to sessions on time, pay at the start of each session, attend scheduled appointments, and actively participate in your recovery by working on your home program towards lifestyle changes we are discussing in pelvic health therapy. Completing your intake form thoroughly is the first step of investing in your care.

3. Voluntary termination of care: You may decide to terminate care or ask for my help to find another provider at any time. Similarly, your therapist reserves the right to terminate care without any explanation at any time.

4. Internal and Pelvic Work: You understand that to evaluate and treat your condition, it may be necessary or optimal to do internal and pelvic muscle exams and manual therapy. This does not substitute for exam from a licensed physician. Internal and pelvic techniques will only be performed after consent prior to each technique, and only as pertaining to your therapy goals and functional outcomes. An explanation of the techniques will be given prior to each technique and consent obtained prior to each technique. As the patient, you hold the responsibility to inform the therapist of any conditions that would limit or prohibit your ability to have an internal examination. Even after giving consent for evaluation and treatment, you have the right to change your mind and clearly ask the treatment to be stopped. The focus of internal and pelvic work is to resolve urinary, bowel, bladder, sexual, neural, or pain issues within the pelvis by addressing fascia, pelvic muscle, visceral-fascial and neural relationships. This practice treats sexual dysfunction, such as anorgasmia, erectile dysfunction, pain with intercourse, or other dysfunctions within the scope of pelvic therapist. The treatment may include direct work to the genitals, which will only be done after explaining the technique to the patient. Though techniques and functional goals may involve sexual function, the patient understands the relationship between the client and physical therapist is strictly professional and non-sexual relationship. If at any time confusion arises as to the nature of the relationship, the therapist should be notified and treatment will be terminated immediately.

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Please date and sign (first name and last), to confirm you have read the above statement and agree to all terms.
Patient First Name *
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