Form

Continence and Pelvic Wellness Clinic
1516 West Mequon Road, Mequon, WI 53092
262-240-1202

Patient Order for Therapy
 Name:  _____________________
 Address:  ___________________
                ___________________
 Phone:  (___) ____ – ________
 DOB:  ____ / ____ / ____

Problem list (check all that apply):

__Chronic Pelvic Pain Syndrome
__Prostatitis
__Vulvodynia/Vulvar Vestibulitis
__Dyspareunia
__Urinary dysfunction
__IC/Painful bladder syndrome
__Bowel dysfunction
__IBS
__Post surgical pain
__Post radiation pain
__Painful scars
__Prostate Cancer: Pre or Post surgical PFM therapy
__Other (Please define): _____________________
Additional Information: _________________

The above patient is referred to occupational therapy for
evaluation and treatment of soft tissue and musculoskeletal
disorders related to the above problems. Biofeedback
training may be included in therapy. I find it medically
necessary for my patient to receive this therapy.

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    __________________          ____________

    Physician’s Signature                      Date

Fax to: 262-240-1205
www.pelvicwellness.com