Tubal Reversal Prepayment Account
Prescheduling Questionnaire
The Tubal Reversal Prepayment Account Prescheduling Questionnaire can be found at the bottom of this page.
If you are having problems completing this form on-line we can email this form to you or you can by-pass this completely and schedule by phone directly with the nurse.
By completing this questionnaire and the nurse interview, you can then start your Reversal Prepayment Account with greater confidence you will be a good candidate for tubal surgery. You will also be in a better position to more quickly take advantage of any reduced rate surgeries should they become available.
- Submit this Reversal Prescheduling Questionnaire before paying your scheduling fee.
- Have the contact information for your nearest lab so the scheduling nurse may fax a lab order for any required lab testing. You can use any local lab but we encourage you to consider LabCorp. Their website (www.LabCorp.com) will help you find the lab nearest you. The nurse will need the name of the lab and the phone and fax numbers for the lab.
- If you do not have all of the information requested in this questionnaire you are welcome to skip those sections. You can provide the required information to the nurse at the time of your phone prescheduling interview.
- Please call at any time if you have questions.
- After you submit this form and pay your scheduling fee, a scheduling nurse will call you within 1 to 2 business days to complete your phone prescheduling interview. Prescheduling interviews do not occur on weekends or after 5 pm East Coast time.
- A nurse will only call you to conduct your prescheduling health interview after your questionnaire has been completed, you have paid the scheduling fee, and we receive confirmation your scheduling fee has been paid.
- You will be required to send your lab test results to our office. You or your health insurance company will be responsible for the costs of any medical testing. You will not be allowed to start your Reversal Prepayment Account or submit an initial deposit until we have received and evaluated those test results. Most patients will only need to send the results of a complete blood count (CBC) from the previous 3 years. Depending on your medical history, you may be required to obtain other test results.
After completing this questionnaire and the nurse phone prescheduling interview, you can then send your initial contribution. This prescheduling process will allow you to save towards your surgery with greater confidence you will be the best candidate possible when you are ready to schedule. Since you have obtained medical clearance, you will also be able to more quickly take advantage of any reduced surgery rates should they become available.
Reduced rates will only be offered to Reversal Prepayment Account members.
