Please complete the following forms in their entirety and deliver them to our office prior to your first appointment. You may deliver them via U.S. Mail, fax (352.633.2232), or in person. You must have Adobe Reader® installed in order to view and complete the forms. If you do not have Adobe Reader®, you can download it here for free.
- HIPPA Notice of Privacy Practices
- HIPPA Patient Acknowledgement Form
- Authorization for Release of Medical Information to Dr. Nwaubani
- Insurance Provider Information Form
- New Patient Intake / Patient Demographic Form
- Medical History Questionnaire (3 pages)
- Bladder Record (2 pages)
- Pelvic Pain & Urgency / Frequency – Patient Symptom Scale
- Pelvic Organ Prolapse / Urinary Incontinence Sexual Function Questionnaire
- Pelvic Floor Distress Inventory (2 pages)
Neuromodulation is a clinically proven, FDA approved (since 1997) therapy for management of Refractory OAB (Overactive Bladder), Incomplete Bladder Emptying (not due to outflow obstruction), and Fecal Incontinence (the latest since March 2011).