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Pelvic Floor Therapy Intake Form

Asks about referring provider, bladder & urinary symptoms, and bowel function assessment. Built for pelvic floor physical therapy and pelvic rehabilitation clinics.

Questions
15
Pages
2
Time
about 4 min

Includes

  • E-signature
  • Consent agreement
  • Insurance details
  • Medication list
  • Conditions checklist
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Your practice

Pelvic Floor Therapy Intake Form

Page 1 of 2 · Your information

Live preview. Tap through it like a patient.

Who it is for

  • Pelvic floor physical therapy and pelvic rehabilitation clinics
  • Women's health physical therapy practices
  • Urogynecology and continence therapy centers
  • Postpartum recovery and diastasis recti rehabilitation programs

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What's inside

Page 1 · Your information

  1. Full NameText · Required
  2. Date of BirthDate
  3. Email AddressEmail
  4. Phone NumberPhone
  5. Referring ProviderText

Page 2 · Additional details

  1. Obstetric & Birth HistoryLong Text
  2. Pelvic & Abdominal Surgical HistoryLong Text
  3. Current MedicationsMedications
  4. Medical ConditionsConditions
  5. Insurance InformationInsurance Info

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Pelvic Floor Therapy Intake Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

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Questions

Responses are encrypted, only your team can see them, and a BAA is included.

Yes. You can add, remove, reorder, or reword any of the 15 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Yes. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Pelvic Floor Therapy Intake Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

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