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NEW CLIENT REGISTRATION
Laura McKaig Physical Therapy LLC
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DATE OF BIRTH*

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REFERRING PHYSICIAN
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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.
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EMERGENCY CONTACT
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Updated January 22, 2022

Laura McKaig Physical Therapy LLC

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.
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Updated January 22, 2022

Laura McKaig Physical Therapy LLC