Name

Email Address

Former last Name (s)

Phone Number

City

State

Date of Birth

What is Your Prominent Language

Who may we thank for referring you?

Weight (Pounds)

Height

BMI

History of Fibroids * If Yes you must have a pelvic ultrasound and have your results faxed to (727) 796-8764 History of Fibroids * If Yes you must have a pelvic ultrasound and have your results faxed to (727) 796-8764YesNo

History of Anemia History of AnemiaYesNo

Total Pregnancies

# Living Children

# C-Sections

# Ectopic Pregnancies

Tubal Ligation Year

My Records My RecordsI will EMAIL my records to information@tubalreversalexperts.comI will fax my records to 727-796-8764There are NO RECORDS

My tubes were tied My tubes were tiedSame time as giving birthDay after giving birthWeeks/Months after giving birthYears after giving birth

I have a scar at I have a scar atBikini lineNaval (Belly Button)Bikini line and navalNo scar

List ALL Medical Conditions, Surgeries & Medications

Ready to schedule Ready to scheduleYesNo

Acknowledgement - By entering your name Here, 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.

Relationship to patient Relationship to patientSelf (I'm the patient)SpouseSon / DaughterOther RelativeFriend / Co-Worker