Please click on the links below to open the files in PDF format to print and fill out. Click on the "back" button in your browser to get back to this main site.

  1. Initial Pelvic Pain Questionnaire - Female
    Initial Pelvic Pain Questionnaire - Male
  2. Past & Family Medical History Form
  3. Important Information
  4. Demographic Information
  5. Medical Record Release Form

You may send them back to us by either snail mail, e-mail or fax.  Our office will then contact you for making an appointment.

Office address: 623 W. Union Blvd. Suite 5,  Bethlehem, PA, 18018

E-mail:  info@TheEchenbergInstitute.com

Office fax:  610-868-0204

Click here for Treatment Program Options