Patient Information
Diagnosis - To Be Completed by Healthcare Provider
Does the patient suffer from pelvic floor dysfunction or incontinence?
Did the patient suffer with recurrent/persistent low back pain with this pregnancy?
Does the patient have genital prolapse?
Does the patient have a BMI over 30 with an increased wound infection risk?
Does the patient have severe diabetes and a history/or increased risk for wound infections, slow healing wounds?
*Did the patient have a 3rd or 4th degree vaginal tear with a previous delivery?
*Did the patient have a breakdown of the suture, opening of skin with infection in a previous delivery?
*Did the patient have an episiotomy with a previous delivery?
*Did the patient have a rectal fissure repaired after a previous delivery?
*Did the patient have a prolonged recovery from a vaginal tear in a previous delivery?
*Did the patient have a prior c-section with wound infection and/or wound disruption?
*Does the patient have diastasis or hernia from a prior c-section or vaginal delivery?
Insurance
Provider Info
Product & Sizing - To Be Completed By Healthcare Provider
MamaStrut Postpartum Care System

Physician Must Select Size:
Measure below the belly and around the pelvis/hips.
Postpartum/Post-op: Double truss with standard pads, 8" wide medical grade quality, latex free, anti-microbial abdominal, pelvic-sacral and lumbar support secured by attached compression shorts for maximum stability with 3 attached and adjustable pelvic floor/perineum/hernia elastic tension straps. Use with or without adjustable tension straps to customize placement and amount of support. Removable and adjustable pouch with gel packs for cryotherapy or heat therapy in combination with compression to reduce pain, swelling and pressure for the lumbar, hips abdomen and perineum. Latex free.
Forms must be sent with supporting clinic notes verifying medical necessity.