First Name *

Last Name *

Phone *

Email *

What pelvic health concern are you seeking care for? *

How are these symptoms affecting your daily life? *

How long have you been experiencing these symptoms? *

Have you previously received treatment for this concern? *

Yes

No

If yes, please briefly describe the type of treatment you received. *

Do you currently have health insurance? *

Yes

No

I am underinsured or unable to afford my deductible or out-of-pocket costs

What financial or access barriers have made it difficult for you to receive pelvic health treatment? *

Are you available to attend appointments at our clinic location? *

Yes

No

I would need additional information about scheduling and location

Are you comfortable receiving care in a supervised teaching clinic? Treatment may be provided by a licensed clinician or student participating in the PelviEd Residency Program under direct guidance and supervision. *

Yes

No

I would like more information

Is there anything else you would like us to know when reviewing your application? *

How did you hear about the PelviEd Pro Bono Clinic? *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Submission of this application does not guarantee acceptance into the pro bono clinic. Applications are reviewed based on clinical appropriateness, financial or access barriers, provider availability, and the educational needs of the supervised residency clinic. If selected, you will be contacted to complete a separate medical intake and schedule your first appointment.

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