MD Consultation

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.
Name*

First NameMiddle NameLast Name
What is your date of birth?*

MonthDayYear
Date
What is your age?*
Why are you scheduling a MD consultation?*

Endometrial ablation (procedure to decrease periods)Uterine artery embolization (procedure to block the arteries of the uterus)Diagnosed with a blood clotting disorderDiagnosed with a platelet disorder (easy bleeding)History of a DVT (deep vein thrombus) or PE (pulmonary embolus) or other blood clotJust want to talk/more information about reversalOther
What is your email address?*

Confirmation Emailexample@example.com
What is the best phone number for the nurse to reach you?*
Please enter a valid phone number.
Would you like a phone consultation or in-person office consultation?*

Phone consultationIn-person office consultation
Consultation phone calls could take up to 45 minutes. What is the best number for the doctor to reach you for the phone consultation?*
Please enter a valid phone number.
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)?*

YesNo
Please list medications*
Do you have any allergies?*

YesNo
Please list all allergies:*
Please list medical problems:*
Please list all previous surgeries:*
How many biological children do you have?*
How many vaginal births?*
How many C-sections?*
Why are you considering reversal surgery?*

Would like to become pregnantTreatment of tubal ligation symptomsBoth pregnancy and treatment of tubal ligation symptoms
What are your symptoms?*
Please calculate your BMI. Your BMI will need to be less than 37 on the day of your surgery to be considered a candidate for surgery.*
Do you have a period every month?*

YesNo
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) ?*

YesNo
How many days does your period last?*
Are you currently in a relationship with someone you are trying to have a child with?*

YesNo
Does this person have biological children?*

YesNo
How many biological children does he have?*
Has he had a semen analysis (sperm test)?*

YesNo
What were the test results of his semen analysis (sperm test)?*
Do you have any comments for the staff or doctor?
After submitting this form I have 90 days to complete my consultation.*

I understand
If the consultation has not been completed within 90 days then I must repay the consultation scheduling fee.*

I understand
Once the consultation has been completed the consultation fee is non-refundable.*

I understand
The consultation fee is separate from and not included in the cost of surgery.*

I understand
A 3.9% credit card processing fee is apploied to all credit card transactions with A Personal Choice.

You cannot pay the consultation fee with CareCredit.

Consultation Fee*

Physician Preoperative Consultation Product Image

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

$389.96

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Total

$0.00

Credit Card

Please digitally sign below before submitting this form*

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Date*

MonthDayYear
Date
MD Consultation Notes
General counseling items

Provided an overview of surgery (hotel stay, BMI limit, out-patient procedure)Benefits of tubal reversal (allows natural pregnancy andmultiple chances)Risks of tubal reversal (infection and ectopic pregnancy)Discussed early pregnancy monitoring protocolDiscussed alternative treatment of in-vitro fertilizationDiscussed alternative treatment of in-vitro fertilization using a gestational surrogateDiscussed alternative treatment of in-vitro fertilization using donor eggs
Endometrial ablation counseling items

Informed patient pregnancy after ablation is not generally recommendedDiscussed risk of pregnancy after ablation: increased risk of infertility, recurrent pregnancy miscarriage, fetal growth restriction, premature delivery, still birth, cesarean delivery, difficult to remove placenta, and hysterectomy.)Discussed observational studies of pregnancies after ablation: approximately 50% will be live born and approximately 30% of the live born infants will be born before 37weeksTo optimize chance of pregnancy recommend hysteroscopy prior to reversal to asses and treat possible intra-uterine adhesions after ablation procedureInformed patient she can come for reversal without hysteroscopy but advised hysteroscopy prior to reversal
Essure coil removal and reversal

Discussed risk Essure coil fragmentation at time of removalDiscussed risk of uterine rupture and recommendations for C-section if tubouterine implantation performed
Comments
Minutes spent in consultation*
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Date*

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Date
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Physician Preoperative Consultation

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MD Consultation Notes