Pre-Payment for Tubal Reversal

Complete this form, print it out, and send a copy with each payment you mail in for your pre-payment account. No Personal Checks Accepted. Please mail in only Money Orders or Cashier's Checks made payable to: Charles W. Monteith MD PA

Mail this form with your payment to:
Chapel Hill Tubal Reversal Center
Attn: Pre-Payment Plan
3613 Haworth Drive
Raleigh, NC 27609

Last name:
First name:
Middle Initial:
Date of birth:
Address:
Address line 2:
City:
State: Zip:
Home phone:
Cell phone:
Email

Amount of Payment: $

Is this a payment for a new or existing account

Activation of the pre-payment account requires an initial $500 non-refundable administration fee payable by cashier’s check or money order. The non-refundable administration fee will be applied towards the total cost of surgery.

Additional contributions must be $100 or more, payable by cashier’s checks or money orders only. Full payment must be completed within 3 years. If the pre-payment account is closed before having surgery then the total amount less the $500 non-refundable administration fee will be returned.

Signature: __________________________________         Date: __________________________________