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Requisition Form
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Requisition for Physiotherapy treatment
pelvic floor rehabilitation
Pelvic Health Practitioner: Jillian Sauder
Date: 28-04-2026
Clinic: Coach House Therapeutic Centre
Phone Number: 519-707-0599
Email: jillian@thecoachhousetc.ca
Website: http://www.thecoachhousetc.ca
Location: 150 King Street South Waterloo Ontario N2J 1P6 Canada
Patient's Full Name (Required)
Patient's Email Address (Optional, to receive requisition)
Patient's Phone Number (Required)
Relevant Clinical Information (Optional)
Diagnosis: ● Stress Incontinence● Urge Incontinence● Pelvic Organ Prolapse● Post-Prostatectomy● Overactive Bladder (OAB)● Constipation● Pregnancy/Post-Partum Assessmen● Diastasis Recti● Coccydynia● Enuresis● Encopresis● Hesitation/Dysynergia● Dyspareunia● Vulvodynia/Vestibulodynia● Vaginismus● Endometriosis● Pudendal Neuralgia● Pelvic Pain● Interstitial Cystitis (IC)/ Bladder Pain Syndrome (BPS)● Chronic Non-Bacterial Prostatitis/Chronic Pelvic Pain Syndrome● Other
Services Required: ● Pelvic Floor Rehabilitation at therapist's discretion● Pain Education● Manual Therapy● Electrical Muscle Stimulation● Biofeedback● Urinary Diary● Behavioural Education● Vaginal Cones● Dilators● Massage Therapy● Other
Referring Physician
Physician's Email or Fax Number