A Personal Choice Medical Records Upload Form

A Personal Choice Medical Records Upload Form
Current legal name*

First NameLast Name
Date of birth*

MonthDayYear
Please confirm your Date of birth*

MonthDayYear
Name at time of tubal ligation procedure*

First NameLast Name
Email address (please use an email you check frequently)*

Confirmation Emailexample@example.com
Best phone number for contact*

Area CodePhone Number
Confirm best phone number for contact*

Area CodePhone Number
Are you sending records to be evaluated for*

Tubal ligation reversalEssure reversal surgery (get pregnant)Essure removal surgery (not get pregnant)Vasectomy reversal surgeryTubal surgery to repair blocked tubes from causes other than tubal ligation
Is this the first time you have sent us records?*

YesNo
Have you had an abdominoplasty (tummy tuck)?*

YesNo
Have you had a C-section?*

YesNo
How many C-sections? (Enter 0 if no C-sections)?*
Medical history
Surgical history (c-sections, tummy tuck, gyn surgery, etc).
Current medications
Calculate Your BMI: Enter Height And Weight
To change the BMI calculator to accept kilograms and centimeters click the two arrow symbols next to the weight box. *
- Our maximal BMI for women is 37 and for men the maximal BMI is 45.
- You will not be allowed to have surgery if your BMI if above the maximal limit on the day of your consultation.
- Your BMI will officially be calculated on the day of your consultation.
Do you have a comments for the staff? If you are sending additional records please explain why you are sending the these extra records.
Attach your medical records

Please read the information below before you attach your medical records to our HIPAA Compliant Medical Record Upload Portal
We do not require your medical records to be a candidate for tubal reversal but it is much better if you let us do a free review of your records before you schedule surgery.

We are not able to accept or review your records if they do not show your full name.

We will only accept PDF or Word files for review.

If you have jpeg/png images or screen shot images of your records then you will first need to convert them to PDF files before uploading. You can easily convert a photo to a PDF on your phone. If you need instructions then Google how to convert JPEG to PDF on your phone type.

These are the records we typically review. Most of these records are not longer than two (2) pages:
- Tubal Ligation Operative Report
- Pathology Report (Only for cut and tied tubal ligations)
- Essure or Adiana Operative Report
- Essure 3 Month Confirmation X-ray Report (if test was done)
- Ultrasound reports to evaluate for uterine fibroids, cysts, etc
- Other test results as requested by our nurses
Do not upload your entire medical record!
Upload your medical records before submitting your Medical Record Upload Form. You may upload multiple files. Please limit your uploads to the minimum amount requested.

Browse Your Device Files

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Do not forget to attach medical records before submitting this form!
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A Personal Choice Medical Records Upload Form

Calculate Your BMI: Enter Height And Weight

Attach your medical records