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