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Requisition Form
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Requisition for Physiotherapy treatment
pelvic floor rehabilitation
Date: 09-10-2025
Pelvic Health Practitioner: Nelly Faghani
Clinic: Advanced Pelvic Physiotherapy Centre - Toronto
Location: 123 Edward Street, Suite 1124 Toronto Ontario M5G 1E2 Canada
Patient's Full Name
Patient's Email Address
Patient's Phone Number
Relevant Clinical Information ( Optional )
Diagnosis: Stress IncontinenceUrge IncontinencePelvic Organ ProlapsePost-ProstatectomyOveractive Bladder (OAB)ConstipationPregnancy/Post-Partum AssessmenDiastasis RectiCoccydyniaEnuresisEncopresisHesitation/DysynergiaDyspareuniaVulvodynia/VestibulodyniaVaginismusEndometriosisPudendal NeuralgiaPelvic PainInterstitial Cystitis (IC)/ Bladder Pain Syndrome (BPS)Chronic Non-Bacterial Prostatitis/Chronic Pelvic Pain SyndromeOther
Services Required: Pelvic Floor Rehabilitation at therapist's discretionPain EducationManual TherapyElectrical Muscle StimulationBiofeedbackUrinary DiaryBehavioural EducationVaginal ConesDilatorsMassage TherapyOther
Referring Physician
Telephone Number
