Step 1 of 7

  • Health History

    This questionnaire is to be completed by clients of all ages and genders. There will be questions that do not apply to you. Simply leave these blank. *Required Questions
    Pure Pelvic Health does not provide direct billing to extended health insurance but we do want to make it as easy as possible for you to submit a claim. Please let us know which insurance companies you will be submitting to (Primary & Secondary Coverage) and we'll do our best to make sure you have everything you need to submit for reimbursement. Please Note: Pelvic floor physiotherapy will be reimbursed up to your policy limits for physiotherapy.
  • Providing a cell number is very helpful during the COVID-19 pandemic so we can call you in your vehicle when you can come inside for your appointment.
  • MM slash DD slash YYYY
  • Please list the problem(s) that you would like to address with pelvic floor physiotherapy.
    Please help us understand any other pelvic floor issues, symptoms or dysfunction that you may be experiencing.