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PELVIC FLOOR RESTORE
INTAKE FORM
Personal Details
Full Name
Email
Phone
Date of Birth
*
required
Preferred Language
Preferred Contact Method
Phone
Email
Text
Gender Identity
Gender Identity
Male
Non-binary
Prefer not to say
Prefer to self-describe
General Health Questions
Are you currently:
Pregnant
Postpartum (within 12 months)
Neither
Do you experience any of the following:
Bladder leakage
Pelvic pain
Core muscle weakness
Low back or hip discomfort
None of the above
Do you have any implanted medical devices or metal in your body?
Pacemaker
Hip replacement
Other metal implant
No
Do you have any medical conditions we should be aware of?
Have you used EMS pelvic chairs or similar technology before?
Yes
No
Service Preference
Select
I’d like to visit a local clinic
I’m interested in mobile/home service
Not sure / need more information
Referral Source
How did you hear about Pelvic Floor Restore?
Google / Search Engine
Instagram
Facebook
TikTok
Walk-in / Saw signage
Referred by a friend
Referred by a physician
Other
Newsletter Subscription
Would you like to receive updates, wellness tips, and exclusive offers?
Yes
No thank you
Consent & Submission
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terms and conditions
Your Signature
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