Patient Referral

Thank you for referring your patient to Southern Urogynecology! We look forward to serving your patient and will be sure to dictate and send your patient’s office visit report to you for your records.

Please complete the following form and fax it to us. We will then schedule an appointment and fax it back to you. Please contact your patient with the appointment information.

For patients with internet access, we request that they visit our website and locate the For Patients Tab. Under this heading is a list of forms for all new patients to complete. We ask that they download the forms, complete them and bring to their upcoming appointment. This website also provides useful information for patients to know what to expect at their visit, as well as our practice policies.

If your patient does not use the internet, we will gladly mail out a New Patient Packet. We again ask that they complete the packet and bring with them to their visit.

If for some reason the patient is unable to complete the packet PRIOR to their appointment, we request that they arrive approximately 20-30 minutes in advance to allow time for them to complete the paperwork and the registration process.

Patient Referral Intake Form

A New Approach


We gear our consultation services to the referring physician’s needs and preferences:

If you request evaluation only, the patient receives a comprehensive evaluation of her incontinence as well as any pelvic floor defect. This evaluation includes clinical and, if indicated, urodynamic testing. We immediately forward to you a letter reviewing the findings. We then make recommendations to you regarding both surgical and non-surgical therapeutic options.

If you request evaluation and management, we evaluate the patient as described above. Our letter to you reviews the findings and outlines initial management. For patients who require reconstructive surgery, we forward to you a copy of the discharge summary sheet and a follow-up letter after the second post-operative visit. If you have full operating privileges at the hospital where the surgery is performed, and want to participate in the surgery, we will make all efforts to accommodate you. For patients who do not need surgery, we correspond with you regularly regarding the patient’s progress. In all cases, we inform your patient clearly of the consultative nature of the referral, and direct her back to you after the completion of our services. No patient will be referred to another physician without your input.

What Our Consultation Service Involves:

At the patient’s first visit, we do a complete history and physical, with emphasis on pelvic floor defects and disorders of the lower urinary tract.

If, after clinical assessment, the diagnosis is relatively clear and the patient is not a surgical candidate, we will outline initial management without the aid of formal multichannel urodynamics.

In more complex cases, where the etiology of the incontinence is not clearly evident upon clinical evaluation, we have the patient come in for a second visit for urodynamic evaluation. (Urodynamic testing is also performed prior to surgery when indicated.) This session takes 45 minutes to an hour, including post-procedure counseling and review of the results.

We promptly communicate to you the results of the urodynamic testing.

Urodynamic Evaluation

Includes the following:

  • Uroflowmetry
  • Water-filled multichannel cystometry
  • Urethral pressure profilometry
  • Measurement of abdominal leak point pressure
  • Sphincter electromyography
  • Urethrocystoscopy

A description of these tests, in consumer-friendly language, is available for your patients on this site.