Name

Phone Number

E-mail Address

My Tubal Was Done On

When would you like to have your procedure?
Immediately (next two weeks)in 30 daysin 60 daysin 90 daysUndecided

Age

Height
feet inches

or centrimetres

Weight
pounds or kilograms

Why are you looking to have this procedure

Do you have asthma?
YesNo

Do you have a history of Hypertension or heart related issues?
YesNo

How many children do you have via child birth?

How long ago did you get your Tubal Ligation?

What was the technique used for your tubal reversal (if you do not know, leave it blank).

Did you have any C-sections?
YesNo

If yes, how many

What previous surgeries have you had performed?

Do you take any medications? Which ones?

Do you have any medical conditions that we should be aware of?
YesNo

Have you ever had a problem with Anesthesia?
YesNo

Are you willing to take time off work to recover from this surgery?
YesNo

Do you have your Tubal Ligation report ( Upload here )