Bladder Installation Therapy Screening Call

Eligibility Screening Call

Is Bladder Installation Therapy Right for You?
Full Name

First NameLast Name
Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider to come to my homeIn OfficeSent to My HomeOther
What date and time work best for you for a screening call? Please note this doesn't automatically qualify you. *
YesNo Please note: Treatment cannot commence during an active infection.
Less than 6 months6-12 months1-2 years2+ years
☐ None of the following☐ Long-term or prophylactic antibiotics☐ D-Mannose or supplements☐ Dietary / fluid modifications☐ Pelvic floor physiotherapy☐ Bladder retraining☐ Oral medications (e.g. antimuscarinics, beta-3 agonists)
Disrupted sleepDifficulty exercisingImpact on work or employmentReduced social activitiesRelationship difficultiesAnxiety or low moodReduced quality of life generally
Yes- New prescriptionYes- MaintenanceNone
What Medication (including supplements) are you taking daily?
☐ None of the following☐ Kidney disease or reduced kidney function☐ Urethral stricture or anatomical abnormality☐ History of bladder or pelvic surgery☐ Active bladder cancer or history of bladder cancer☐ Pregnancy or currently trying to conceive☐ Immunosuppressive condition or treatment☐ Diabetes
YesNo
YesNo- I would like more support
YesNo- I would like more support
YesNo
List Allergies:
Please upload or send any lab such as cultures or blood work to info@clinova.solutions

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By Completing this form, you agree to the following:

1. Telemedicine Consent

2. Privacy Policy

3. By providing your phone number, you consent to receive text messages from our care team regarding appointments, care coordination, treatment updates, and important account-related information. Message frequency may vary. Standard message and data rates may apply. You may opt out at any time by replying STOP.

The information I have provided is accurate to the best of my knowledge.
I understand that home bladder instillation therapy requires proper training and adherence to the prescribed protocol.
I agree to contact my clinical team if I experience any unexpected side effects or complications.
I consent to my information being used to support my care at Clinova Solutions.
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Eligibility Screening Call