Patient Forms

Were you referred for Pelvic Floor Dysfunction (pelvic pain, incontinence?)

Were you referred for Vestibular Dysfunction (dizziness, BPPV, imbalance?)

Is your Primary or Secondary insurance Medicare?

(Choose more than one if needed) Please tell us why we are seeing you?

Neck or numbness/tingling in arm(s)
Low back, mid back or numbness/tingling in leg(s)
Shoulder or Arm, including Lymphedema
Elbow, Wrist, or Hand, including Lymphedema
Hip, Pelvis or Leg, including Lymphedema
Knee, Foot, or Ankle, including Lymphedema

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