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: Chapel Hill Tubal Reversal Center

Mail this form with your payment to:
Chapel Hill Tubal Reversal Center
Attn: Pre-Payment Plan
109 Conner Drive Suite 2200
Chapel Hill, NC 27514

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

Amount of Payment: $
Check if you would like to be notified upon receipt of your payment:
This is a payment for a new or existing account

If you have general questions or would like to request a refund please call 919-968-4656, Monday - Friday, 8:00 am to 5:00 pm Eastern Time and ask for the business office.

In the event that a refund is requested all money in your pre-payment account will be refunded less a $250 processing fee. Please note that refunds may take up to 30 days to process.