I, the undersigned patient, acknowledge and understand that I have been referred for evaluation and treatment of pelvic floor dysfunction. Pelvic floor dysfunctions include, but are not limited to, urinary or fecal incontinence; difficulty with bowel, bladder, or sexual functions; painful scars after childbirth or surgery; persistent sacroiliac or low back pain; or pelvic pain conditions.
I understand that to evaluate my condition, it may be necessary, both initially and periodically, to have my therapist perform an internal pelvic floor muscle examination. This examination is performed by observing and/or palpating the perineal region including the vagina and/or rectum. This evaluation will assess skin condition, reflexes, muscle tone, length, strength and endurance, scar mobility, and function of the pelvic floor region. Such evaluation may include vaginal or rectal sensors for muscle biofeedback.
Treatment may include, but not be limited to, the following: observation, palpation, use of vaginal weights, vaginal or rectal sensors for biofeedback and/or electrical stimulation, ultrasound, heat, cold, stretching and strengthening exercises, soft tissue and/or joint mobilization, and educational instruction.
I understand that in order for therapy to be effective, I must come as scheduled unless there are unusual circumstances that prevent me from attending therapy. I agree to cooperate with and carry out the home program assigned to me, and accept responsibility for complying with the home program. If I have difficulty with any part of my treatment program, I will immediately discuss it with my therapist.
I understand that treatment outcomes are not guaranteed.
1. The purpose, risks, and benefits of this evaluation have been explained to me, and I have had an opportunity to discuss these risks and benefits with my provider. All of my questions regarding the procedure have been answered to my satisfaction.
2. I consent to evaluation and treatment of pelvic floor dysfunction.
3. I understand that I can terminate the treatment at any time.
4. I understand that I am responsible for immediately telling the examiner if I am having any discomfort or unusual symptoms during the evaluation.
5. I understand that while my health insurance plan will be billed for this procedure, my insurance plan may not cover pelvic floor services and I will be responsible for the costs of care in the event of non-coverage. I have received a copy of the Integrated Gastroenterology Consultants, P.C. Patient Financial Policies, and acknowledge that such policies will apply to my pelvic floor treatment.
Option 6 only applies to office visits, not Telehealth/virtual visits.