Contact Us

To find out if you are eligible for a Tubal Reversal and to receive a quote, complete the form below.

Your Personal Information

First Name

Do not include middle name

Last Name *

Current Last Name

Former Last Name(s)

ANY/ALL Last Name(s)

Email *

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Confirm Email *

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Phone Number *

City *

State *

Today's Date

Date of Birth *

MM/DD/YYYY

Age

Is This Your Correct Age? *

Please Correct Your Date of Birth

What is Your Prominent Language?

Select All that Apply

I can read English

I can speak English

I cannot speak or read English

I prefer to communicate in my native language

I have an interpreter to translate

I will need an interpreter to translate

Who May We Thank for Referring You?

Your History

Weight (Pounds) *

Height (Feet) *

Height (Inches) *

History of Fibroids *

History of Anemia *

You must have a pelvic ultrasound. *

I will have my results faxed to (727) 796-8764

Total Pregnancies *

# Living Children *

# C-Sections *

# Ectopic Pregnancies *

Tubal Ligation Year *

My Records *

My tubes were tied ... *

I have a scar at ... *

List ALL Medical Conditions, Surgeries & Medications *

Your Medical Records

Attach Surgery & Pathology Report From Your Tubal Ligation

Maximum upload size: 35MB

Surgery Scheduling

Ready to Schedule? *

Preferred Surgery Month & Year *

Thank you.

Please Look for our email reply in your In-box & Spam folder (just in case) for subject line "Tubal Reversal Experts"

Acknowledgement

By signing below, I attest that the information submitted is true and accurate. I understand this is a Self-Pay elective surgery and may not be billed or reimbursed through insurance. All forms are available to me via the website, including my financial obligations.

Name of Person Completing Form

Relationship to Patient

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You will receive an email from us shortly with further instructions.