Name *

First Name

Last Name

Phone

(###)

###

####

Please check any symptoms that apply to you

Bladder Issues (general)

Pain with sex

Constipation

Bowel issues (general)

Difficulty with erections

Difficulty with orgasms

Pain with penetration (tampons, gyn exams)

Low back pain

Hip pain

Jaw pain

Please note: This session is a virtual COACHING/consult session and it is NOT physical therapy. This session cannot replace medical advice. *

Yes, I understand!