New Client Intake

New Client Intake

Welcome to The Pelvic Way™! Please complete this form to help us provide personalized care for your pelvic health needs.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
What type of care are you interested in?

Virtual/Telehealth (Available in Florida and California)Mobile/In-home (Florida Only)Not sure yet
The Pelvic Way™ currently offers care to clients located in Florida and California.

In-home visits are available only in Florida. Telehealth services are available in both states.

Still unsure which option fits your needs? Just select “Not sure yet” and we’ll guide you from there.
Where are you located?
For example:Tampa, FL or Palm Springs, CA
Mobile in-home pelvic floor therapy is available in Valrico, Plant City, and Brandon, Florida.

If you are located outside this area, extended travel may be available for an additional fee. Please include your location when requesting care so we can confirm availability.
Have you had Pelvic Floor Therapy before?

YesNoI'm not sure
Are you currently pregnant or postpartum?

YesNo
Do you have a preferred day or time for your appointment?
(For example: Mondays after 2 PM, weekday mornings, or anytime after July 10.)
Would you like a superbill?
A superbill is a detailed receipt that a client can submit to their insurance for possible out-of-network reimbursement.
Tell us about why you're seeking care.
(For Example: postpartum healing, pelvic pain, incontinence, etc.)
How did you hear about The Pelvic Way™?
Knowing how you found us helps us reach and support more people like you.
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