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(816) 569-2802 Plaza (913) 498.8492 OP Email Us Referrals

As a convenience, we are happy to provide the following forms on our website.

First-Time Patient Forms

Please complete the following two forms prior to your first appointment. These are required as they are your consent for treatment, as well as our cancellation policy, your authorization for release of medical records and your financial and insurance responsibilities:

Informed Consent Form

Online Version / Print Version (choose one, online preferred)

Medical History Questionnaire

Online Version / Print Version (choose one, online preferred)

 

Outcome Measure Forms

Please complete the following at your therapist’s request.

Male Prostatitis Symptoms Index

Online Version / Print Version (choose one, online preferred)

Female Prostatitis Symptoms Index

Online Version / Print Version (choose one, online preferred)

Vulvar Pain Index

Online Version / Print Version (choose one, online preferred)

Constipation Index

Online Version / Print Version (choose one, online preferred)

Female Sexual Function Index

Online Version / Print Version (choose one, online preferred)

Oswestry Disability Index

Online Version / Print Version (choose one, online preferred)

Pelvic Floor Disability Index (PFDI-20)

Online Version / Print Version (choose one, online preferred)

Initial Pelvic Pain Inventory

Online Version / Print Version (choose one, online preferred)

Pelvic Pain Goal Inventory Status

Online Version / Print Version (choose one, online preferred)

Pelvic Floor Inventory Questionnaire (PFIQ-7)

Online VersionPrint Version (choose one, online preferred)

 

Discharge

Patient Feedback Survey

 

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