Forms

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

New Patient Forms

1. Patient History Form
2. FMLA/Disability
3. Medical Records Release Form 
4. Medical Records Release Form – Dr. Lou Patients – Southside Regional Medical Center
5. Notice of Privacy Practices

General Forms

1. Voiding/Leaking Diary
2. Financial Assistance Application
3. 2022 Financial Assistance Limits

Women’s Health  Physical Therapy Forms

1. Physical Therapy New Patient History Form 
2. Female Pelvic Floor Intake Questionnaire
3. Bladder Symptom Questionnaire
4. What to Expect at First Physical Therapy Visit

 

Educational Resources

1. Urostomy Patient Guide

 Post-Operative Instructions

1. Cystoscopy
2. Ureteral Stent Placement
3. Ureteroscopy
4. Vasectomy