Fax: 219 769-1609 Mail: Dr. Dennis Streeter D.O. 119 E. 89th Ave. Merrillville, IN 46410
Secure Online Medical Information Sheet
Please provide the necessary information to help determine your candidacy for tubal ligation reversal and/or vasectomy reversal. Please note that this information is strictly held confidential.
Date:
Full Name:
Maiden Name (Tubal Reversal Candidates Only):
Address (w/ City, State, Zip):
Phone:
Email Address:
Cell Phone:
Date of Birth:
Social Security #:
Is This For A:
Tubal Ligation Reversal
Vasectomy Reversal
Date of Tubal Ligation or Vasectomy:
Please List Any Medical Problems:
Please List any Past Surgeries:
Please List any Medications you are on: (Please indicate if taking any blood thinners such as Aspirin, plavix, and coumadin.)
Please List any and ALL Allergies: (Including latex and food allergy)
Do you Smoke?:
No
Yes
What is your Height:
What is your Weight:
What is your Spouse's Name & Age:
Please List the Ages and Sexes of your Children:
Comments:
NOTE: Please Submit a copy of your operative report to expedite the scheduling of your procedure.
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