Please complete the forms below to the best of your ability. The more information you send, the more accurate our evaluation.

MEDICAL RELEASE FORM
If you do not have copies of your medical records, we can request them for you from your physicians or hospitals. Please fill out the form above, sign it, and fax it or mail it to us as soon as possible. We will need one form each for every doctor and hospital that has your records.

Our Fax Number:
1-773-542-7150

Our Mailing Address:
Laparoscopic Tubal Reversal Center
3714 W. 26th St., Ste. 200
Chicago, IL 60623