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  • Tubal Reversal Prepayment Account Scheduling Questionnaire

  • Starting A Reversal Prepayment Account

     Complete this form to start a Reversal Prepayment Account (RPA).

    • You will have three (3) years to save towards your surgery
    • We will email RPA members when discounted surgery rates are available

    You can start an RPA if your BMI is over 37 or if you are anemic, but you will not be able to schedule surgery until your BMI is less than 37 and your anemia has resolved. 

    Steps to Start an RPA

    You will need to have the fax number of your local lab for us to send an order for your Complete Blood Count (CBC) test. If you have a CBC test result from within the last three (3) years then you can use that test result to start your RPA. Please discuss with the scheduling nurse.

    If you are ready to start an RPA then these are the steps you will need to take:

    1. Complete this form and pay the scheduling fee 
    2. A nurse will call you within 48 hours to complete RPA scheduling over the phone
    3. The nurse will email you RPA contracts
    4. Electronically return all signed RPA contracts
    5. Complete required lab work as soon as possible
    6. Send your initial deposit. The minimum amount to start an RPA is $500

    You must electronically return signed RPA contracts and send the minimum deposit of $500 within 30 days of completing RPA phone scheduling.

    Please call the office if you need additional instructions.

  • 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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    Pick a Date

  • Please use your legal name as it appears on your driver’s license or government issued identification.

  • Please use an email you check often.


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  • We recommend you avoid heavy lifting and bending for four (4) weeks after your reversal surgery.

    You can resume sexual activity as soon as you feel comfortable.

  • Tubal Ligation and Other Medical Records

  • 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 and we cannot match records under a previous name to a current name.

  • Screening Laparoscopy

  • All patients should be aware we offer an optional 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 form then DO NOT SUBMIT this form OR PAY the scheduling fee. 

    Call and speak with a nurse for more information.

  • 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

  • You are permitted to start an RPA if your BMI is over 37. 

    You will not be able to schedule surgery until your BMI is less than 37.0

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

    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

  • 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 during their stay in Raleigh North Carolina.

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

    These prescriptions will be sent to a Raleigh pharmacy before your consultation.

  • If you have had an endometrial ablation you will need to have a mandatory phone/office consultation with Dr. Monteith before you can start a RPA or 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.

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

  • Lab Testing Before Starting an RPA

  • We require a complete blood count (CBC) to start an RPA and 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.

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

    If you are starting an RPA you can send us a recent CBC (within the last three (3) years) and we will accept those results to start your RPA.

    Search the internet 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 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 your RPA scheduling with the nurse.

  • After Surgery Follow up

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

  • When you schedule 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 having 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 Give You A Copy Of Our Recommentations And A Copy Of Your Tubal Reversal Operative Note After Your Surgery. We Will Also Email These Same Records To You So You Will Have An Electronic Copy Of Your Records.

     

  • Responsible Adult

    For planning purposes, you need to be aware 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 can not consider your RPA completed until:

    • You return your signed RPA contracts
    • Your lab work results have been received and reviewed by our office
    • Your initial RPA deposit has been received

    You have thirty (30) days to complete your RPA from the time the nurse completes your RPA phone interview.

    The scheduling fee is not refundable under any circumstance.

    It you have something in your history you are concerned about you should call and speak with us before submitting this form.

  • RPA 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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