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Lizanne Pastore PATIENT FORMS FOR NEW PATIENTS

General Intake Forms: ALL New Patients
These are the forms that all new patients will be asked to fill out and bring to their first appointment:
1. Patient Information Sheet (1 page)
2. Cancellation Policy (1 page)
3. Notice of Privacy Practices (READ-ONLY: for your information only, please do not bring to your appointment)
4. Receipt of Privacy Practices (1 page)

Orthopedic Forms: Orthopedic Patients ONLY
Pain Management in San Francisco In addition to the general intake forms, please fill out the following:
1. Consent Form (1 page)
2. Medical History Information (1 page)

Pelvic Floor Forms: Pelvic Floor Patients ONLY
Marin Pain Management In addition to the general intake forms, please fill out the following:
1. Consent Form for Pelvic Floor Treatment (2 pages)
2. ONE of the following questionnaires depending on your symptoms:
Bay Area Pain Management Sonoma Pain Management Female Incontinence (5 pages)
Female Pelvic Floor Pain (4 pages)
Pregnancy Back Pain (4 pages)
Male/Female Bowel/Gastrointestinal Dysfunction (3 pages)
Male Pelvic Floor Pain (4 pages)

Questions? Email Lizanne@lizannepastore.com or call 415.504.8772.

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Physical Therapy Office in Marin County