Forms

For your convenience the following forms are available for you to review or complete:

New Patient Forms

1. Patient History Form
2. Physical Therapy Intake Questionnaire (new physical therapy patients only)
3. FMLA/Disability
4. Medical Records Release Form 
5. Medical Records Release Form – Dr. Lou Patients – Southside Regional Medical Center
6. Notice of Privacy Practices

General Forms

1. Voiding/Leaking Diary
2. Financial Assistance Application
3. Financial Assistance Guidelines

Women’s Patient Health Forms

1. Survey Introduction
2. Bladder Retraining
3. Nocturia Diary
4. Female Pelvic Floor Intake Questionnaire

Educational Resources

1. Urostomy Patient Guide
2. Patient Information about Ultrasound
3. Prostate cancer — Diagnosis, Treatment and Recovery