Online or in person consultation: preliminary assessment 
Please complete this form so that we can assess your condition and decide, if online consultation is a suitable method of work for your individual case
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Package chosen (tick preliminary assessment if you are not sure yet about the consultation type) *
Name, surname  *
Email address *
Phone number  *
Date of birth  *
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Brief description of current health issue  *
Have you been given definite diagnosis for your condition ? *
If yes, what is the diagnosis  *
What are your expectations of the consultation? *
Have you had pelvic floor physiotherapy before? For current or any other conditions? Please provide short description.
Payment method 
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