PD New Patients

Today's Date

First Name*

Last Name*

Email*

Phone*

Check the box below if you agree to the following:*

I agree to the privacy policy and terms & conditions provided by the Pelvic Docs. By providing my phone/email, I agree to receive text messages and emails from OneAccord PT & the Pelvic Docs.

Address/City/State/Zip Code*

What is your Gender?*

Select or enter value

What is your Date of Birth?*

Which of our locations would you prefer for your appointment?*

Select or enter value

Are you an existing patient?*

Yes

What brings you in to see a physical therapist?*

Our waitlist for new patients is currently 2-6 weeks. How urgent is your need to see a specialist?*

Extremely Urgent (I need to see a specialist ASAP)

Urgent (I need to see a specialist within 1-2 weeks)

Not Urgent (I can wait 2-6 weeks to see a specialist)

Do you have a doctors referral?*

Yes

Paying for your services:*

**We offer a hybrid care model that blends traditional insurance-covered services with specialized treatments like dry needling, shockwave therapy, and our exclusive "Movement is Life" program. These offerings aim to elevate your pelvic health journey beyond the standard care.

Checking the box below signifies your understanding our hybrid model. You acknowledge that while insurance may cover standard treatments, certain specialized services from The Pelvic Docs might incur out-of-pocket costs.**

Please upload your supporting documents here*

EXAMPLE: A picture of your insurance card (front and back), workers comp paperwork and/or doctors referral etc.

Drag and drop files here or

What is your #1 Goal to achieve with Physical Therapy?*

What is your #2 Goal to achieve with Physical Therapy?

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