I understand that if I undertake physical therapy for any pelvic floor dysfunction, it will be beneficial for my therapist to perform an evaluation of the pelvic floor, initially and periodically to assess muscle strength, length, range of motion and scar mobility. Palpation of these muscles is most direct and accessible if done via the vaginal and/or anal/rectal canal.
Treatment procedures for pelvic floor dysfunction include, without limitation, patient education, therapeutic exercise, neuromuscular reeducation, therapeutic modalities, manual techniques including myofascial release and joint and/or soft tissue mobilization and instruction in the use of massage tools and/or dilators for self-treatment.
The therapist will explain all evaluation and treatment procedures to me and I may choose not to participate with all or part of the evaluation and treatment plan.
I understand that if I am uncomfortable with the evaluation or treatment procedures AT ANY TIME, it is my responsibility to inform my therapist immediately and the evaluation or treatment procedure will be discontinued and alternatives will be discussed with me.
I understand that no guarantees have been or can be provided to me regarding the success of therapy.
I understand that although every attempt is made to avoid it, it is not unusual to have increased soreness after pelvic floor evaluation or treatment procedures.
I have read or had read to me the foregoing and any questions that I have asked have been answered to my satisfaction.
I hereby voluntarily agree to allow the physical therapists at Cardenas & Associates Physical Therapy to perform both initial and periodic evaluation of the pelvic floor and to perform manual treatment techniques via the vaginal and/or anal/rectal canal.
Patient Name
Signature
Date
Δ
