Tubal Reversal Forms

Forms to Complete for Tubal Ligation Reversal

Jeannie Morin
Medical Secretary

These forms will help you provide us with important information.

Medical Records Release Form

Complete our Medical Records Release Form, print it out, and then fax or mail it to the Medical Records department of the hospital where you had your tubal ligation surgery.

Our Medical Records Release Form requests that the designated facility fax or mail your tubal ligation records directly to us along with the records release form. Without the form included, we will not have the necessary information in order to contact you to review your records.

Fax Cover Sheet

If you already have a copy of your tubal ligation records, please complete our Fax Cover Sheet, print it out and fax your records, along with the completed fax cover sheet to fax: 919-869-1976. Without the completed fax cover sheet we will not have all the necessary information needed to be able to contact you after your records have been reviewed.

1. Medical Records Release
2. Fax Cover Sheet
3. Medical and Anesthesia History
4. Pre-Payment Form
5. Tubal Reversal Surgery Checklist
6. Pregnancy Report Form
7. Feedback Form

Preparing For Tubal Reversal

After you have scheduled a date for your tubal reversal, please complete and submit the Medical and Anesthesia History Form and print out a copy of the Tubal Reversal Surgery Checklist to ensure your successful preparation for your reversal.

If you already have or would like to start a pre-payment account, complete the Pre-Payment Form, print it, and mail it with your payment each time you make a payment toward your account. See Fee and Financing for details about the pre-payment plan.

Pregnancy Report Form

We want to be informed as soon as you become pregnant after your tubal reversal. You can use the Pregnancy Report Form, or call or email us when you have a positive pregnancy test. An essential part of our long term care is follow-up with you and your local doctor during your pregnancy.