Thank you for providing Dr. Hodges with background about your child’s toileting difficulties.
Please fill out a separate form for each child.
Once we have received your form, along with your payment via PayPal, your time zone, and your preference for FaceTime, Zoom, Skype, or phone, we will contact you to schedule the consultation. Please hang on to any x-rays until after we have confirmed a time slot. At that point, you can email your images to Dr. Hodges at firstname.lastname@example.org.
*Please note: This form cannot be saved online. You may want to scroll through or print it before filling it out so that you have the information on hand.
List any medical professionals who have treated your child for toileting difficulties. During the consultation you can let Dr. Hodges know whether you’d like him to consult with your physician.
Please select any that apply:
Is your child currently taking any prescription or over-the-counter medications (including MiraLAX)?
Please indicate whether your child has now or has ever been diagnosed with any medical conditions, including the following: