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