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TUBAL REVERSAL FORMS
FORMS TO COMPLETE FOR TUBAL LIGATION REVERSAL

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) 883-4036. 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. Pre-Payment Form

4. Tubal Reversal Surgery Checklist

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.

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.

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.

28 thoughts on “Forms to Send”

  1. L. says:

    What is the quickest someone has become pregnant after having reversal surgery? Does reversal surgery put you at risk for an ectopic pregnancy? What is the BMI restrictions for a tubal reversal? I am in the 29-32 BMI range, but do not have a huge abdomen. Thank you for your time.

    1. Dr. Monteith says:

      We will email you more information.

      1. We have had many patients become pregnant the month after tubal reversal surgery. We advise our patients they can start trying to become pregnant as soon as they feel comfortable.
      2. Tubal reversal does increase the risk of ectopic pregnancy. The risk of ectopic pregnancy after reversal is about 10%.
      3. Our maximal BMI limit is 37.

      We charge $6400 total plus $125 to schedule and we are located in Raleigh, North Carolina. Insurance will not pay for tubal reversal surgery.

      You should send us your tubal ligation records for a free review.

      Patients pay in full and out-of-pocket at the time of scheduling. All you have to pay for in addition to the surgical fee is the cost of travel, hotel, and food. Patients stay in Raleigh a total of 2 nights and 3 days. The consultation is the first day, surgery the second day, and postoperative visit is the third day.

      We do have a prepayment tubal reversal plan that allows you to save towards your reversal over a 3 year period.

      Although $6,400 seems expensive…the alternative treatment in-vitro fertilization (IVF) average $12,000 to $14,000 and is about 40% successful!

      The main advantage to tubal reversal is that every month you have a chance and you can become pregnant more than once. On average, about 2 out of every 3 women become pregnant with tubal reversal surgery.

      Call us at (919) 977-5050 8am to 5pm eastern standard time and we would be happy to speak with you about reversal surgery at our center.

      The following link will answer most of your questions about reversal. This is the MOST HELPFUL INFORMATION to read when considering reversal at our office. Each question has a link to more information about the question: Frequently asked questions about tubal reversal

  2. Yanira says:

    Hola …tengo 41 yrs old i have my tube tie sincer 2004 .. But i try get my record but i cant get it .. Can i still get my reversal tube ??? Plz let me know assp …

    1. Dr. Monteith says:

      Yanira
      We can reverse most tubal ligations….even if you have no records!

      You should try to get your tubal ligation operative and pathology reports by going to the medical records department in the hospital where your tubal ligation was performed.

      You should be able to request a copy of your tubal ligation operative report and a copy of the pathology report (a pathology report is only created when a segment of the tube is removed (typical with tubal ligations that involve tying and cutting the tubes). We can review these records free of charge.

      You can personally request your record from the hospital where your tubal ligation was done using our Medical Records Release/Request form: Medical Records Release Form

      You dont have to have your records to have tubal reversal at our center. You should consider our optional screening laparoscopy if you cannot get your tubal ligation records. Many patients come to us for reversal without records because they know we can repair most tubal ligations.

      We charge $6,400 for tubal reversal surgery. Many women may not be able to obtain their records…some will have surgery because they know we can repair most tubal ligations. Others will add on a screening laparoscopy.

      If you choose to have a screening laparoscopy we can look with a camera during the surgery and see if your tubes are repairable. If your tubes are not repairable or then we would offer you a refund of your surgical fee.

      For more information: Screening laparoscopy and surgery refund

      For more information: Screening laparoscopy and scar tissue

      Call us at (919) 977-5050 8am to 5pm eastern standard time and we would be happy to speak with you.

      The following link will answer most of your questions about reversal. This is the MOST HELPFUL INFORMATION to read when considering reversal at our office. Each question has a link to more information about the question: Frequently asked questions about tubal reversal

  3. Tanya says:

    How much is it to review my medical records to see if I’m a candidate for reversal? I had essure done in 2012.

    1. Dr. Monteith says:

      We dont charge to review your records. Call us at (919) 968-4656 8am to 5pm eastern standard time and we would be happy to speak with you.

      The following link will answer most of your questions about reversal. This is the MOST HELPFUL INFORMATION to read when considering reversal at our office. Each question has a link to more information about the question: Frequently asked questions about tubal reversal

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