New Patient Forms
The physician determines your candidacy for surgery based on the history you provide in addition to review of your medical records.
Your records can be helpful in providing information about the type of tubal ligation that was performed, anything additionally noted during the surgery and possibly tube length.
Please complete the form fully and include your current last name and former last name (if applicable).
Remember to request both the Operative Report and Pathology Report from the hospital where your tubal ligation was performed.
Or Upload your files HERE
Tubal Reversal Surgery Forms:
Please print, sign and return forms to fax (727) 796-8764, attention – Sam:
- FFI Arbitration Agreement
- Notice of Privacy Practices
- New Patient Form
- Financial Policies
- Microsurgical Tubal Reconstruction Consent
- Exploratory Laparotomy Consent
- Waivers of Liability
- Surgery Center Information
- Forms to Keep Packet
- Forms to Print Complete and Return
Call us now at 1-866-882-2573 (1-866 – TUBAL REVERSAL) or email using our Contact Us Form and let us help your dream of a baby come true.