Tubal Reversal Forms

Tubal Reversal Forms

Please follow these steps to continue the process:

  1. Fill out the contact information form below and submit it on-line 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.
  2. Please contact the doctor or hospital where you had your tubal ligation surgery or Essure/Adiana procedure and fax the Tubal Medical Release Form below to that facility in order to obtain your operative and pathology reports.  You or the facility where you had your procedure must send us these forms in order to move to the next step.
  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.

Please fill out and submit this secure form: Tubal Reversal Patient Form

Please download and give this to the facility/doctor where you had your tubal ligation performed:  Medical Release Form

Check your BMI here to see how your weight affects the cost of your tubal reversal surgery.

 **A simple CBC blood test has to be performed at at least one week prior to surgery and should be no more than 30 days prior to the surgery.  If this blood work is not back prior to your surgery, your surgery will be cancelled and all fees forfeited. 

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