Chapel Hill Tubal Reversal Center
109 Conner Drive Suite 2200, Chapel Hill, NC 27514 (919) 968-4656

Medical Records Release Form

How To Obtain Your Tubal Ligation Operative Report

Please fill in your information and then press "Submit"

*	The date of your tubal ligation was:	MonthJanFebMarAprMayJunJulAugSepOctNovDec Day12345678910111213141516171819202122232425262728293031 Year200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985other
*	Your name at the time of the tubal ligation was:
*	Name of hospital or doctor's office:
*	Your current name is:
*	Your date of birth is:
*	Your social security number is:
*	Your current address:
	Address line 2:
*	City
*	State
*	Zip Code
*	Your home phone:
	Your work phone:
	Your cell phone:
*	Your email address:
	(If you do not have an email address type "None")

More information

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Website updated May 13th, 2008 © Chapel Hill Tubal Reversal Center
109 Conner Drive Suite 2200, Chapel Hill, NC 27514 (919) 968-4656   

109 Conner Drive Suite 2200, Chapel Hill, NC 27514 (919) 968-4656