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TUBAL REVERSAL FORMS
FORMS TO COMPLETE FOR TUBAL LIGATION REVERSAL

To send us your medical records please refer to the information on our “Contact Us” page.

For more information on sending records: Contact Us: Sending records for review


Medical Records Release Form

Use this form if you are asking Medical Records department or a hospital or facility to send records to you or Dr. Monteith.

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 medical records fax or mail your tubal ligation records directly to us along with the Medical Records Release Form. If they don’t include the form with your records, we will not have the necessary information to contact you after we review your records.

If you would like your medical records sent directly to you then remove, cross out, or line out our mailing address and insert your mailing address. Once you get your records then you will know when you have them and you can send them to us.

Many patients have issues where they ask their doctor or hospital to send records…and the reality is you never know when (or if) they ever send the records as requested.


Medical Records Cover Sheet (also called Fax Cover Sheet)

Use this form if you have your medical records and would like to send your records directly to us.

If you already have a copy of your tubal ligation records, please complete our Medical Records Cover Sheet, print it out and fax or email your records to us directly.

The Medical Records Cover Sheet contains all of your important health and contact information. Without the completed Medical Records Cover Sheet we will not have the necessary information to determine if you are a candidate for surgery and we will not be able to contact you after your records have been reviewed.

  • You can fax your medical records along with the completed Medical Records Cover Sheet to: (919) 883-4036.
  • You can email your records along with the completed Medical Records Cover Sheet to: ContactUs@tubal-reversal.net

You are welcome to fax or email us your records but we recommend you use our HIPAA complaint Medical Record Upload Portal for greater security and privacy.

For more information: Contact Us: Sending records for review


Pre-Payment Form

Use this form if you would like to make a deposit (not the very first deposit) to your Tubal Reversal Prepayment Account.

Pre-Payment Form

Please be aware when you open your RPA you will need to sign an RPA contract and make your first deposit using the contract sent to you.

This RPA Pre-payment form is for contributions made to your account after the account has been opened.


Preparing For Tubal Reversal

After you have scheduled a date for your tubal reversal, please print out a copy of the Tubal Reversal Surgery Checklist to ensure your successful preparation for your reversal.


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.


Birth Report Form

We are eager to hear when your baby is born. Please complete the Birth Report Form, or call or email us when you have a baby. Your comments are extremely important and provide both hope and inspiration for other couples. With your permission, we will add a page for your baby in the Testimonials section of our website.

Have Questions? We’re Happy To Help!

We provide a unique surgical experience with personalized attention and one-on-one care. We make every effort to make your surgery less of a process and more of a life’s experience. Please use the buttons below for answers to our frequently asked questions.

What Our Patients Are Saying

“We had our surgery on 3/18/15 and on 02/02/16 our 7 pound 11 oz baby girl was born! I’m 34 years old and had tubal ligation done via clamps 8 years prior so this surgery really does work! 8 years later I had the reversal and 9 years later we were blessed with our little girl! So many doctors tried to talk us out of it-wanted us to do IVF to get our money-however praise God we went with this because it does WORK! Dr M is amazing and his staff! The area is beautiful where his office is, and if you do this procedure it will be the best money you ever spend!”

– Charlee-Belle M., Surgery

“From the very first phone call, the staff at A Personal Choice has been amazing! They have answered our numerous questions, concerns and have been amazing. They never give you false hope, but give you the complete story. I am so happy that we chose Dr. Monteith and his staff to make our dreams a reality. Can’t wait to start trying to have a baby. I would and have recommended Dr. Monteith to ANYONE wanting a tubal ligation or vasectomy reversal. Thank you all so much for giving us this chance!”

– Angela W., Essure Reversal

“Excellent service overall! Each stage of the process was carefully explained in great detail: how the procedure works, what to expect during the procedure, what to expect after, possible side effects. Dr. Monteith himself is very knowledgeable and experienced and quite personable too. He has a great sense of humor and uses it generously to put patients at ease. I highly recommend him and his staff to anyone considering either a vasectomy or a vasectomy reversal.”

Chris B., Vasectomy Reversal

“The perfect little angel that I’m holding in my arms right now is the best testament to what Dr. Monteith and his staff do for people. We could not be happier with our decision to use Dr. Monteith. His staff are just amazing. Our entire experience was just a dream! Thank you, from the bottom of our hearts, thank you!”

Jamie B., Reversal of Cut & Tied Tubes

GET IN TOUCH WITH US

Ask The Doctor

Your questions about reversal surgery will be answered directly and promptly by Dr. Monteith. Please read our most frequently asked questions before submitting your questions. Dr. Monteith will not respond to general medical questions or if you are a patient of another doctor and are contacting him because your doctor is unavailable.* If you have been a patient at our reversal center and have specific questions about your medical care you should contact the reversal staff directly at (919) 977-5050.

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Have Questions? Leave a comment here or visit our contact page.

8 Comments

Zoila Reply

Quisiera que me ayuden para poder aserme la cirugía


    Dr. Monteith Reply

    Zoila
    Please call us next week at (919) 977-5050 and ask to speak with Oyuki or Karla. They speak Spanish and can help you.


Anonymous Reply

If 7.5 and 7.0 cm were removed of tubes (with fembriated end removed) during a csection (3rd), would you consider enough left to attempt to reversal?


    Dr. Monteith Reply

    Both of your tubes were removed in their entirety. You can only do IVF if you want to become pregnant.


Adis Reply

Buenas tardes Doctor quiero aser una pregunta ..fui ligada ase 7 años y quiciera poder tener un bebe seria posible..pues icieron mi operasion en.mi pais y no tengo acseso a mi archibo medico..digame que puedo aser


    Dr. Monteith Reply

    Call us at (919)977-5050 and ask to speak with Cheily or Oyuki. They speak Spanish and can help you.


Yorleny Gurrero Reply

Hola Dr. que se puede hacer en mi caso que no tengo el informe de mi operación, ya que fue el 5 de febrero del 2004


    Dr. Monteith Reply

    We are closed until January 2nd. Call us at (919)977-5050 and ask to speak with Oyuki. She speaks Spanish and can help you.

Have a Question? Drop Us A Line!

If you are considering reversal surgery and have questions about the procedure, fill in the form below and we'll get back to you as soon as we can! If you would like to speak with a nurse for a Free Consultation then feel free to call us at (919) 977-5050.

Please view our most frequently asked questions before sending your questions.

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