Request an Appointment

If you are interested in learning more or scheduling an appointment with a contienence or pelvic health care provider, please complete the form below. A member of our team will contact you as soon as possible.

Please note: We cannot process emergency requests from this form. If you are having a medical emergency, please call 911.

When you submit this form, your information will be sent to the appropriate Middlesex Health staff, who will help you schedule an appointment or complete your request.

All fields are required unless otherwise noted.

First Name

This field is required

Last Name

This field is required

Email Address

This field is required and must be a valid email

Phone Number

Must be in 555-555-5555 format

Briefly describe why you are seeking an appointment

This field is required

Let us know about the symptoms that bother you most. This will help us connect you with the right providers. (optional)

Fecal Incontinence

Pelvic Pain

Unable to reach toilet in time

Urinary Frequency (>8 times/day)

Urinary Incontinence with coughing/sneezing/laughing/lifting

Urinating more than once per night

Sexual Dysfunction

This field is required

Date of Birth (optional)

Must be in mm/dd/yyyy format

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Request an Appointment

If you are interested in learning more or scheduling an appointment with a contienence or pelvic health care provider, please complete the form below. A member of our team will contact you as soon as possible.