I voluntarily consent to receive physical therapy evaluation and treatment services

provided by The Healthy Pelvis and its licensed physical therapist(s).

Physical therapy may include assessment, therapeutic exercise, manual therapy,

education, pelvic health assessment and treatment, and other clinically appropriate interventions.

I understand that the purpose of physical therapy is to improve function, reduce pain,

promote healing, and enhance quality of life. No guarantees regarding outcomes are made.

I may refuse treatment, request modifications, ask questions, or withdraw consent at any time.

I acknowledge participation may involve temporary soreness, discomfort, fatigue,

aggravation of symptoms, dizziness, bruising, or injury.

PELVIC FLOOR INTERNAL EXAMINATION AND TREATMENT CONSENT

The Healthy Pelvis

Pelvic floor physical therapy may include an internal examination and/or treatment of the pelvic floor muscles. Internal examination and treatment may involve vaginal and/or rectal assessment depending on the patient’s anatomy, symptoms, diagnosis, and treatment goals. These muscles may be assessed to evaluate muscle strength, coordination, tension, tenderness, mobility, and function.

The purpose of an internal examination and treatment is to assist in the evaluation and management of conditions that may include, but are not limited to:

• Urinary incontinence or urgency
• Bowel dysfunction or constipation
• Pelvic pain
• Pain with intercourse or intimacy
• Pregnancy and postpartum concerns
• Pelvic organ prolapse
• Post-surgical rehabilitation
• Male pelvic health conditions

I understand that the physical therapist will explain the examination and/or treatment procedures before they are performed and will answer any questions I may have.

I understand that an internal examination or treatment is optional and that I may decline, postpone, modify, or stop the procedure at any time, for any reason, without affecting my right to receive other physical therapy services.

I understand that consent for internal examination and treatment may be withdrawn at any time, including during a treatment session.

I understand that I may request the presence of a chaperone during any internal examination or treatment session. A chaperone may also be recommended by the physical therapist.

I understand that I may experience temporary discomfort, tenderness, soreness, emotional responses, spotting, or mild symptom aggravation following an internal examination or treatment. Every effort will be made to ensure my comfort, privacy, dignity, and safety throughout the session.

I understand that gloves and appropriate infection control procedures will be utilized during all internal examinations and treatments.

By signing below, I acknowledge that I have received information regarding pelvic floor internal examination and treatment, have had the opportunity to ask questions, and voluntarily consent to these procedures as deemed clinically appropriate by my physical therapist.

Payment is due at the time services are rendered unless other arrangements

have been made in advance.

Patients are responsible for understanding their insurance benefits, including

deductibles, copayments, coinsurance, authorization requirements, and exclusions.

Any portion of services not covered by insurance remains the patient's responsibility.

For out-of-network plans, a superbill may be provided for possible reimbursement.

Reimbursement is determined solely by the insurance carrier and is not guaranteed.

Please provide as much notice as possible if you need to cancel or reschedule.