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  • Tubal Reversal Scheduling Questionnaire

  • Scheduling Reversal Surgery

    If you are ready to schedule surgery:

    • Your Body Mass Index (BMI) must be below 37
    • You will be required to pay in full for surgery within 24 hours of completion of phone scheduling with the nurse
    • If you are financing all or part of your surgery then you should have made arrangements with one of the financing companies listed on our website before starting this scheduling.

    Do not submit this form if your BMI is above 37 or you are unable to pay in full within 24 hours of phone scheduling with the nurse.

    Please call our office with questions.

    Steps You Will Need to Complete

    You will need the fax number of your local lab for us to send an order for your Complete Blood Count (CBC) test. If you have a recent (previous 6 months) CBC result from your doctor then you may be able to use that test result. Please discuss with our nurse.

    If you are ready to schedule surgery then these are the steps you will need to take:

    1. Complete this form and pay the scheduling fee when finished
    2. A nurse will call you within 48 hours to complete scheduling over the phone
    3. After the phone interview the nurse will email you surgery documents
    4. Electronically return signed documents
    5. Complete required lab work as soon as possible
    6. Send full payment within 24 hours

  • If you are financing all or part of your surgery then you should have arranged financing from one of the finance companies listed on our website prior to submitting this form. 

  • Card Owner

    Please enter name and email address of the card owner without errors.

  • If the card owner is not the patient, then the card owner will need to be physically present with the patient at the time of surgery consultation visit.

    The card owner will be required to sign a credit card authorization in the office on the day of the consultation appointment.


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  • Financial Guarantor

    Please enter name and email address of the person who is the financial guarantor for surgery financing.

  • If another person is using their name and credit score to pay for your surgery using their credit card, CareCredit card, FSA/HSA/Advance Care Card or financing your surgery then they are your financial guarantor :

    The scheduling nurse will need their full legal name and email address because that person will need to sign your financial documents.

    Your financial guarantor will need to be present during your consultation appointment to co-sign your financial contracts in person.


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  • Patient Information

    Please enter information as accurately as possible. Please enter your name, date of birth, and email address without errors.
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  • Please use your legal name as it appears on your driver’s license or government issued identification. Name changes after scheduling cause confusion and errors in your medical records.

    If you change your name after scheduling surgery you will be required to repay the scheduling fee.

  • Please use an email you check often.


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  • Desired Surgery Date

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  • You cannot consider your surgery date confirmed until: 

    • Your signed documents have been returned
    • Your lab test results have been reviewed by our office
    • Your full payment has been received by our office

    DO NOT MAKE TRAVEL OR HOTEL ARRANGEMENTS UNTIL ALL OF THE ABOVE ITEMS HAVE BEEN COMPLETED

  • Tubal Ligation and Other Medical Records

  • Ideally your tubal ligation records (if available) should have been sent to our office and reviewed before starting this scheduling.

    You are welcome to send us records for a free review before submitting this form.

    If you send records after scheduling and we then determine you are not a candidate for surgery we will not be able to refund your scheduling fee.

    We recommend you send your records for a free evaluation before submitting this form.

  • Sending Records

    If you sent records and we did not contact you then you should call our office to discuss. If you did not hear from us then we do not have your records or your contact information.

    These are common problems we encounter when records are sent to our office:

    • Hospitals or doctors will not send records as requested
    • Your records may be sent to our office under a previous name
    • Your records will not have your current contact information

    Please be aware if you have requested your records be sent to our office then you are responsible for contacting us to confirm your records have been receieved by our office.

    We cannot determine if something was requested and not sent to us.

    We cannot match records under a previous married name to a current contact name.

  • Screening Laparoscopy

  • All patients should be aware we offer a screening laparoscopy procedure. 

    This is an optional procedure that can be added on to your reversal surgery for an additional fee.

    During laparoscopy we insert a small camera into your belly button at the start of the reversal surgery. 

    A laparoscopy is never REQUIRED to have surgery with our office.

    The screening laparoscopy is optional and should be thought of as a 'reversal insurance policy'. There is an additional fee for the screening laparoscopy.

    Benefits to screening laparoscopy: If your tubes cannot be repaired your time under anesthesia is shorter and you would receive a refund of your surgery fee less the screening laparoscopy fee.

    We recommend you consider a screening laparoscopy if your tubal ligation meets any of the following criteria:

    • No operative or pathology reports are available for review
    • Multiple clips or rings were used
    • More than 3 cm of tube was removed
    • Tubal coagulation (or burning) was done
    • Multiple procedures performed on each tube
    • Fimbriectomy tubal ligation was performed
    • History of c-sections or history of pelvic adhesions (scar tissue)
    • Essure with a history of previous c-section
    • Tubal ligation was performed in the Caribbean or Latin America

    Please speak to the Scheduling Nurse if you are interested in adding a screening laparoscopy to your surgery.

  • High Risk Medical Conditions

  • If you have any of the high risk medical conditions listed in this section then DO NOT SUBMIT THIS FORM AND PAY SCHEDULING FEE. Call and speak with a nurse.

  • Do not submit this form and pay scheduling fee. Call and speak with a nurse.

  • Do not submit this form and pay scheduling fee. Call and speak with a nurse.

  • Do not submit this form and pay scheduling fee. Call and speak with a nurse.

  • Do not submit this form and pay scheduling fee. Call and speak with a nurse.

  • Do not submit this form and pay scheduling fee. Call and speak with a nurse.

  • Do not submit this form and pay scheduling fee. Call and speak with a nurse.

  • Do not submit this form and pay scheduling fee. Call and speak with a nurse.

  • Do not submit this form and pay scheduling fee. Call and speak with a nurse.

  • Do not submit this form and pay scheduling fee. Call and speak with a nurse.

  • Do not submit this form and pay scheduling fee. Call and speak with a nurse.

  • Do not submit this form and pay scheduling fee. Call and speak with a nurse.

  • Do not submit this form and pay scheduling fee. Call and speak with a nurse.

  • The above conditions are high risk conditions.

    If you have any of the conditions above then STOP.

    Do not complete this form and do not pay the scheduling fee.

    Please call to speak with a Scheduling Nurse.

  • Body Mass Index Calculator

    We require your BMI be less than 36.9 to have surgery at our center

  • If your BMI is over 37.0 you will not be able to have surgery until your BMI is less than 37.0

    Do not submit this form.


    Call and speak with a scheduling nurse for advice.

    All patients will have their height and weight measured and official BMI calculated during their consultation apointment.

    Often patients will enter incorrect information at the time of scheduling because:

    • They are not certain about their height or weight
    • They are over the maximal BMI limit and hope to lose weight before their surgery

    If you are over the BMI limit at the time of your consultation appointment your surgery will be cancelled and you will lose 100% of your surgery fee.

    Exceptions are never made to the BMI policy.

  • Medical History

  • If you take phentermine, semaglutide, or tirzepatide you will need to stop these medications 14 days (2 weeks) before surgery.

    These medications can increase the chance of an anesthesia complication. You will need to stop these medications at least two (2) weeks before your surgery.

  • Blood Thinners, Blood Clots, Blood Clotting Disorders, Strokes

    If you are currently taking a prescription blood thinner, have been diagnosed with a DVT/PE, have a disorder that increases the risk of having a serious blood clot, or have had a stroke then you will need to have a consultation with a hematologist or your local doctor before you can schedule surgery.

    You should complete and submit this scheduling form.

    The Scheduling Nurse will provide more information and will send you a referral letter to take to a hematologist for their recommendations. 

    • If the hematologist does not recommend anti-coagulation (a blood thinner) then you can schedule surgery without any additional testing.
    • If the hematologist recommends anti-coagulation (a blood thinner) after surgery then they will need to provide you with the prescription and instructions on how to take the medication. You will also need to have a phone/office consultation with Dr. Monteith before you can compelte surgery scheduling.
    • If the hematologis recommends anti-coagulation before, during, and after surgery then you would not be considered a candidate for reversal surgery.

  • All patients are provided written prescriptions for pain and nausea medication.

    1. Anti-inflammatory ibuprofen 800mg
    2. Narcotic pain medication
    3. Nausea medication

  • Some patients occasionally request we do not prescribe narcotics (stronger pain medications). 

    We recommend you allow us to prescribe a narcotic for you to take after your surgery.

    You are not required to fill or take the narcotic prescription but at least it will be available to you should you require a pain medication stronger than ibuprofen.

    You will have to pick up the narcotic while in North Carolina. The prescription cannot be transferred across state lines.

  • We will electronically send your prescriptions to the pharmacy indicated above a week before your appointment.

    You may recieve a text message from the pharmacy when your prescription has been filled.

    The medication will be waiting for you upon your arrival to Raleigh.

  • Please bring your health insurance card with you when you travel to Raleigh for surgery. Electronic prescriptions for your post-operative medications will be sent to your indicated pharmacy in Raleigh nearest our office.

    • Your health insurance should pay for these medications when filled at a local pharmacy.
    • Please be advised: Medicaid or Medicare will only pay for prescription medications if the prescriptions are filled in the state where those cards were issued. Medicaid or Medicare outside of North Carolina will not pay for prescriptions in the state of North Carolina.
    • Presciptions will only be sent to pharmacies in the Raleigh area.
    • We will not send prescriptions out of state BEFORE surgery
    • You may recieve a phone text from the pharmacy BEFORE your consultation appointment informing you that your medication has been filled.

  • If you have had an endometrial ablation you will need to have a mandatory phone/office consultation with Dr. Monteith before you can schedule surgery. If you have completed the mandatory consultation with Dr. Monteith then proceed with completing this prescheduling questionnaire. If you have not completed the  mandatory consultation then call to speak with a scheduling nurse for more  information

  • If you have had pelvic surgery after your tubal ligation we encourage you to send us those records for evaluation.

    This is important because surgeons may have removed additional segments of your fallopian tubes.


    You may not have been informed of removal of parts of your fallopian tube if your surgeon was not aware you were planning on having tubal reversal surgery in the future.

  • You will need to bring any inhalers or breathing medications with you on the day of your consult and surgery.

  • You will need to bring your CPAP machine with you on the day of your consult and surgery.

  • You will need to bring your blood pressure medications with you to your consult and surgery.

  • You will need to bring any diabetic medications with you on the day of your consult and surgery.

  • If you take Dulaglutide (Trulicity), Exenatide extended release (Bydureon bcise), Exenatide (Byetta), Semaglutide (Ozempic), Liraglutide (Victoza,) Saxenda)Lixisenatide (Adlyxin), Semaglutide (Rybelsus) then you will need to....

     

    Stop these medications two weeks before surgery because these medications can cause a higher risk of anesthesia complications.

     

    Do not start these medications within two weeks of surgery.

  • You will need to bring your thyroid medication with you on the day of your consult.

  • Lab Testing Before Scheduling Surgery

  • We require a complete blood count (CBC) to schedule surgery at our center. If you have certain medical problems additional testing may be required. Lab tests are only valid if done 180 days (6 months) before your surgery date.

    Your lab work needs to be completed and sent to us as soon as possible but at least three (3) weeks before your surgery date.

    If you wait to send us your labs within three (3) weeks of your scheduled surgery and there is a problem with your lab tests then your surgery will be postponed and cancellation/rescheduling fees may apply.

    We strongly encourage you to have your lab work done as soon as you complete phone scheduling with our nurse.

    Search the internet or look in your local phone directory to locate a laboratory in your area. We encourage you to consider LabCorp. You can find the nearest LabCorp by searching the LabCorp website and entering your zip code. After you find your nearest LabCorp lab you can use your back button and continue completing this questionnaire.

    If you provide the phone and fax number for the lab you have selected, the nurse can fax an order for your preoperative lab work. If you are unable to obtain lab information at this time you can provide it to the nurse during your phone health interview.

  • It is extremely important you have your lab work completed as soon as you complete phone scheduling with the nurse.

    Delays in completing lab work and having the results reviewed by our office is a common reason for patients having to cancel their surgeries.

  • After Surgery Follow up

    We will provide you a copy of your records after surgery.

  • We Recommend You Follow Up With Your Health Care Provider After Surgery At Our Center

    • We recommend you make an appointment with your health care provider within 6 (six) weeks of your surgery at our center.
    • Ideally we recommend you make your appointment with an Ob/Gyn doctor
    • When you make an appointment do not ask for a surgery post-operative appointment.
    • We recommend you request a Preconception Counseling Appointment. 
    • A Preconception Counseling Appointment is an appointment to discuss the best ways to have a healthy pregnancy. 

    We Will Provide You With A Copy Of Your Records 

    We will provide you with:

    1) A letter of our recommendations to follow after surgery.

    2) A copy of your tubal reversal operative report.

    After your visit with us, we will email you copies of these same documents. This will allow you to have an electronic version of these documents for your records.

    We recommend you take these records to your follow-up visit with your local doctor.

  • Responsible Adult

    A Responsible Adult will need to be with you during your preoperative consultation, the day of your surgery, and the day after surgery. This person must be above the age of 18.

    If you have another person paying for your surgery (financial guarantor) with a credit card or financing then this person must be with you during your consultation to sign our paperwork.

    The responsible adult will need to:

    • Be present during your consultation appointment
    • Remain in our facility the entire time you are having surgery
    • Help you get back to the hotel and take care of you the night of surgery
    • Help you get back to our office for your post-operative consultation
    • Help you travel back home

    If you do not have a responsible adult with you at your consultation appointment your surgery will be cancelled and you will forfeit your entire surgery fee.

  • Surgery Confirmation

  • You cannot consider your surgery date confirmed until:

    1. Your phone scheduling interview with our nurse is completed.
    2. All documents have been signed and retured.
    3. Your lab results have been reviewed by our office
    4. Your surgery fee has been paid in full.

    Once your scheduling interview is completed, all signed documents have been returned, and your surgery fee has been paid then it is safe to make hotel and travel arrangements.

    We may have reviewed your tubal ligation records and informed you that you were a good candidate for reversal surgery based only on the type of your tubal ligation.

    If we uncover any high-risk medical conditions during the phone scheduling interview, we may determine you are not a safe surgical candidate for outpatient surgery under general anesthesia. 

    The scheduling fee is not refundable under any circumstance.

    If you have something in your history you are concerned about you should call and speak with a nurse before submitting this form.

  • Surgery Policies

    By checking each box below you are acknowledging you understand each policy.
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  • A 3.99% card processing fee is added to all credit, health savings account, and flexible spending account card transactions.

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    Surgery Scheduling Fee Product Image
    Surgery Scheduling FeeNon Refundable
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