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American Family Children's Hospital

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Women's Pelvic Wellness Clinic Referrals/Self-Referrals

The UW Health Women's Pelvic Wellness Clinic in Madison, Wisconsin, is committed to comprehensive care for pelvic floor disorders.
Complete the form below and a member of the Women's Pelvic Wellness Clinic staff will contact you within two business days.
Please do not submit urgent questions about your medical care through this website. If you are experiencing a life- or limb-threatening emergency, call 911. If your need is urgent, call your clinic for assistance.

Request a Consultation

* = Required field 

First Name *
Last Name *
Phone Number *
(Please include area code)
Home  Work  Cell
Best Time to Call:
(Please specify the best time of day/day of the week, etc.)
e-mail Address
Who is the patient's physician?
Where does the patient's physician practice?
Does the patient have any of the following? Please check all that apply
Urinary incontinence
Pelvic organ prolapse
Issues with bladder and bowel control
Accidental bowel leakage/fecal incontinence
Recurrent urinary tract infection
Lower reproductive tract fistula
Other (describe below)