• Physician Preoperative Consultation

    Once you submit this form a nurse will call you within two business days to schedule your consultation. We recommend you send pertinent medical records before your consultation appointment.
  • What is your date of birth?*
     - -
  • Why are you scheduling a MD consultation?*

  • Format: (000) 000-0000.
  • Would you like a phone consultation or in-person office consultation?*
  • Format: (000) 000-0000.

  • Most consultations are done by phone. If you would like an in-person office consultation please notify then nurse when you are called to schedule your consultation appointment.

  • Do you take any medications (over the counter or prescription)?*
  • Do you have any allergies?*
  • Why are you considering reversal surgery?*
  • Do you have a period every month?*

  • If you have had an endometrial ablation and you are not having a period every month then you do not have any uterine lining left for pregnancy.

    There is no treatment that can regenerate your uterine lining.

    We would not consider you a candidate for reversal surgery.

    DO NOT PAY THE CONSULTATION FEE!

  • Do you have regular periods (every month lasting at least 3 days) ?*
  • Are you currently in a relationship with someone you are trying to have a child with?*
  • Does this person have biological children?*
  • Has he had a semen analysis (sperm test)?*

  • You cannot pay the consultation fee with CareCredit.

  • Consultation Fee*

    prevnext( X )
    Physician Preoperative Consultation . Fee to have phone or in-person consultation with the physician.
    Physician Preoperative Consultation

    Fee to have phone or in-person consultation with the physician.

    $389.96$389.96
      
    Total
    $0.00$0.00

    Credit Card
  • Clear
  • Date*
     - -

  • MD Consultation Notes

  • General counseling items
  • Endometrial ablation counseling items
  • Essure coil removal and reversal
  • Clear
  • Date*
     - -
  • Should be Empty: