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Pelvic floor clinic calgary referral form

Pelvic Floor Referral Form 2026

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The document outlines the referral process for pelvic floor physical therapy, detailing various diagnoses such as urinary incontinence, chronic pelvic pain, and pregnancy-related pain. It includes instructions for therapists on evaluation and treatment options, emphasizing a comprehensive approach beyond Kegel exercises. Contact information for multiple locations is provided.

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Click ‘Get Form’ to open the Pelvic Floor Referral Form in the editor.
Begin by entering the patient's name and phone number in the designated fields. This information is crucial for contact purposes.
In the 'Diagnosis' section, check all applicable conditions such as Urinary Incontinence or Chronic Pelvic Pain. If there are additional diagnoses, specify them in the 'Other' fields provided.
Fill out any precautions or special instructions that may be relevant for the patient's treatment. This ensures that therapists are aware of specific needs.
Select the type of therapy required from options like Bladder Retraining or Biofeedback/sEMG. You can also add any other specific requests in the 'Other' field.
Finally, have the physician or NPP sign and date the form, including their printed name and NPI number to validate the referral.

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2016	4.8 Satisfied (83 Votes)

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Will insurance pay for pelvic floor therapy?

Is Pelvic Floor Therapy Typically Covered by Insurance? Yesmost insurance plans do cover pelvic floor therapy when its deemed medically necessary.

When to refer to pelvic floor therapy?

Before starting pelvic floor therapy, you must first consult with a physician, such as a gynecologist, urologist, urogynecologist, or primary care doctor, who will assess your symptoms and provide a prescription for treatment.

Who qualifies for pelvic floor therapy?

Conditions treated by pelvic floor physical therapy: Urinary incontinence. Fecal incontinence. Urinary retention or incomplete bladder emptying. Overactive bladder. Pelvic organ prolapse. prolapse. Interstitial cystitis/painful bladder symptoms. Pregnancy and postpartum recovery or symptom reduction.

Is pelvic floor therapy covered by benefits?

Yes pelvic floor physiotherapy is covered by most extended health insurance plans under your coverage for physiotherapy services. Every plan is different in terms of coverage so its a good idea to contact your insurance company to ask how much they cover.

Is a pelvic floor therapist covered by insurance?

Pelvic floor physical therapy is covered by most insurance plans. Whether youre dealing with incontinence, pelvic pain, prolapse, or recovery after birth, were here to help. Let us verify your benefits and walk you through your optionsso you can focus on healing.

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