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Tubal Reversal Forms

Forms to Complete for Tubal Ligation Reversal

These forms will help you provide us with important information.

Medical Records Release Form

Print out and complete our Medical Records Release Form and then fax or mail it to the Medical Records department of the hospital where you had your tubal ligation surgery. Our Medical Records Release Form requests that the designated facility fax or mail your tubal ligation records directly to us along with the records release form. Without the form included, we will not have the necessary information in order to contact you to review your records.

Fax Cover Sheet

If you already have a copy of your tubal ligation surgery records, please print out and complete our Fax Cover Sheet. Then fax your records, along with the completed fax cover sheet to fax: (337) 989-8766. Without the completed fax cover sheet we will not have all the necessary information needed to be able to contact you after your records have been reviewed.

Online Registration/Medical History Forms Link

After you schedule your consultation appointment, one of our nurses will contact you to provide you with the link to complete your registration and medical history forms online. These forms will take you approximately 20 minutes to complete. Before you begin the online forms, you may want to have the following information handy:

  • weight
  • height
  • drug allergies
  • known reactions to anesthesia
  • prior surgeries, years and complications
  • past medical history
  • medications
  • family medical history
  • husband's medical history

Tubal Reversal Surgery Checklist

After you have scheduled a date for your tubal reversal, please print out a copy of the Tubal Reversal Surgery Checklist to ensure your successful preparation for your reversal.

Patient Confidentiality Forms

At Fertility & Women's Health Center of Louisiana all of your medical records are considered confidential information. Our state-of-the-art patient information system complies with all HIPAA (Health Insurance Portability & Accountability Act of 1996) requirements.