Tubal Reversal Forms NCCRM

Please follow these steps to continue the process:

1. Fill out the contact information form here below and submit it on-line securely through this website. You must provide your current height and weight in order for our surgeons to determine if they can perform a tubal reversal procedure on you in our surgery center. Falsifying information on these forms may result in the cancellation of your surgery and forfeiture of fees.  Please note, you will be weighed on the day of your surgery.  Online Form:Tubal Reversal and Essure/Adiana Reversal Patient Form
2. Please contact the doctor or hospital where you had your tubal ligation surgery and obtain operative and pathology reports.  Download this form to obtain your operative notes from the facility/doctor who performed your tubal ligation: Medical Release Form
3. AFTER we receive your operative and pathology reports and you have submitted your on-line application described in step 1, we will contact you to set up a consultation with you. We will contact you after we receive all this information to set up a consultation with you.

After you become pregnant after your tubal reversal surgery or Essure/Adiana reversal surgery, please fill out and submit this form: Pregnancy Report Form