Patient Forms

In advance of your appointment, please print and complete the appropriate forms to bring with you to your evaluation, along with your insurance card(s) and medical referral.

For contact information and maps to our offices, please see our Contact Us page.


Basic Forms for All Patients:

New Patient Information Sheet PDF
HICFA Acknowledgement PDF
HICFA Privacy Notice PDF (Please keep this notice for informative purposes.)
Cancellation Agreement PDF

Orthopedic Patients: New Patient History Form (Orthopedic) PDF
Pelvic Floor Patients: New Patient History Form (Pelvic Floor) PDF



All Medicare Patients, in addition to the basic forms:

Medicare Benefits Authorization PDF
Medications Chart PDF

Medicare Orthopedic Patients, in addition to basic and other Medicare forms:

Brief Pain Inventory PDF


Female Pelvic Floor Patients, in addition to the applicable forms above, please print and complete the forms that relate to your diagnosis:

For all women:
Introduction to Pelvic Floor Therapy for Women PDF (You may read, or print and keep this letter for informative purposes.)
Pelvic Floor Consent for Evaluation and Treatment PDF

For women with pelvic floor pain and tension syndromes, including Vaginismus, Levator Ani Syndrome, Dyspareunia, Painful Episiotomy, Coccyx pain, Vulvodynia, Menstrual pain, Endometriosis, Pudendal Nerve Pain, and Interstitial Cystitis:
Vulvar Pain Functional Questionnaire PDF
Daily Voiding Diary PDF (Please complete for 1 day.)

For women with urinary incontinence and frequency, fecal incontinence, or pelvic organ prolapse:
Pelvic Floor Distress Inventory PDF
Daily Voiding Diary PDF (Please complete for 3 days.)

 

Male Pelvic Floor Patients, in addition to the basic forms, and Medicare forms, if applicable:

Introduction to Pelvic Floor Therapy for Men PDF (You may read, or print and keep this letter for informative purposes.)
Urological Questionnaire PDF
Pelvic Floor Consent for Evaluation and Treatment PDF
Daily Voiding Diary PDF (Please complete for 1 day if you are not experiencing incontinence; complete for 3 days if you are experiencing incontinence.)