Patient Intake
Thank you for contacting The Pelvic Health Clinic. We look forward to meeting you and helping you with your pelvic floor concern. Please take the time to fill out this brief intake so that we can better assist you in making your first appointment.

This form is powered by Gsuite for business. Any information submitted and collected through this form is protected under HIPPA confidentiality policies and will only be used for the purposes of your care with The Pelvic Health Clinic.

Legal Name (First and Last) *
Preferred Name (if different from above)
Address *
Phone *
Email Address^
^Please note that email is not considered a HIPPA compliant means of communication by default. By supplying your email here, you are giving The Pelvic Health Clinic consent to contact you via email in regards to your patient care. This may include treatment, billing, or other resources.
Best means of contact? *
Date of Birth? *
MM
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DD
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YYYY
Do you have a written prescription for pelvic floor physical therapy? *
Please list your referring provider. If none, state N/A. *
Address of referring provider. If none, state N/A. *
Please list your primary care physician. If none, state N/A. *
Please tell us about your concern - details are good. *
Insurance Provider. If none, state N/A. (Although we do not accept insurance, including Medicare and Medicaid, we keep records of your insurance for possible reimbursement purposes. Please bring your card to your first appointment). *
Please list any further questions you may have at this time.
Please check the following statements. Your check indicates that you have read and understood what is contained within.
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