Forms

Before coming in for your first appointment, please be sure to print and fill out the forms below.

Informed Consent Form

If directed by Shannon, please print and fill out the needed forms below.

Bladder Diary

Vulvar Pain Questionnaire

Pelvic Floor Disability Index

Pelvic Floor Questionnaire

Insurance

To schedule an appointment, call, email or click below to set up your visit. Please note, I am an “out-of-network” provider for all insurance plans. I do provide a super bill for PPOs, which allows you to bill your insurance.

Payment for medical care is expected at the time of patient appointments. Our office accepts cash, personal check, Mastercard, Visa, and Venmo.

 

Kindly notify us at least one business day prior to your scheduled visit should you need to cancel or change your appointment. Cancellations with less than 24 hours notice will be charged a $50 cancellation fee.

Phone

805 - 681 - 9108 ext. 2

Fax

805 - 620 - 7752

Address

121 Gray Ave, Suite 100

Santa Barbara, CA

93101

Email

© 2018 by Shannon Dutter. Designed by Zoe Reifel.