Laura McKaig Physical Therapy LLC
Primary Insurance blanks* Member ID# blank* Group # Type a label*
Name of Policy Holder (if different from self) First Name Last Name Date of Birth Date Address Street Address Address Line 2 City State Zip
*We are an in-network provider for Blue Cross Blue Shield, Medicare B, and VA Community Care plans.
Secondary Insurance: blanks Member ID# blank Group # Type a label
Updated January 22, 2022
CONSENT FOR EVALUATION AND TREATMENT OF PELVIC FLOOR DYSFUNCTION
I understand that I have been referred to a physical therapy specialist for evaluation and treatment of pelvic floor dysfunction. This can include urinary or fecal incontinence, difficulty with bowel, bladder, or sexual function, painful scars, persistent back or sacroiliac pain, and vulvar, testicular or pelvic pain.
I understand that to fully evaluate and treat my condition, my therapist may need to perform an external pelvic and perineal exam. An internal pelvic floor muscle assessment may also be included as part of the evaluation and treatment.
I understand that I can request that any of the above evaluation techniques not be performed, and that I can terminate any procedure at any time.
I also understand that I have the option of having a second person present in the room during the evaluation and/or treatment sessions.
I hereby consent to the evaluation and treatment to be provided by the physical therapy pelvic floor specialist at Laura McKaig Physical Therapy LLC.
About how long have you had this problem? blanks* Did it start suddenly or gradually? blank*
Have you had this problem before? blanks If so, what did you do for it?blank
Laura McKaig Physical Therapy LLC 913-940-3923 firstname.lastname@example.org