Patient Forms for New Patients

SECTION 1

General Intake Forms: ALL New Patients will complete 

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)
5. Extra Info: “MIPS” (1 page)
6. Depression Intake Scale (1 page, if you have a diagnosis of depression or bipolar, you do NOT need to do this form)
7. Telehealth Consent: Only for patients doing Telehealth (print only the last page and sign)

SECTION 2

Orthopedic Forms: Orthopedic Patients ONLY

In addition to the general intake forms, please fill out the following:

• Consent Form (1 page)
• Medical History Information (1 page)
  

SECTION 3- Complete these forms if you have a pelvic floor problem. 

Pelvic Floor Forms: Pelvic Floor Patients ONLY

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:

• Female Urinary Incontinence, Prolapse, Pelvic Pain (6 pages)
• Pregnancy Back Pain (4 pages)
• Male/Female Bowel/Gastrointestinal Dysfunction (3 pages)
• Male Pelvic Floor Pain (4 pages)