Refer Your Patient to Vagina Rehab Doctor™

At The Vagina Rehab Doctor Clinic, we are committed to working closely with referring providers to ensure compassionate, evidence-based care for women experiencing vaginusmus, vulvodynia, pelvic floor dysfunction, sexual pain, and intimacy challenges.

We value your trust in our team and are honored to support your patients through their healing journey.

Patient Referral Form

Date

Referring Provider Name

Practice Name

Provider Title

Pelvic Floor Therapist

OBGYN

Sex Therapist

Sexologist

Mental Health Counselor

Nurse

Nurse Practitioner

Clinic Email

Office Address

City

State

ZIP

Provider Phone Number

Provider Social Media Account

Patient First Name

Diagnosis/Patient Chief Concern:

Patient Email

Patient Phone Number

I confirm the patient has consented to this referral.

Refer Your Patient to Vagina Rehab Doctor™

Patient Referral Form

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