Secure Medical Information Form


Submit Method
Internet Submit via internet
Fax/Mail Fax: 219 791-9787
Mail: Family Surgical Solutions, LLC
Dr. Dennis Streeter D.O.
300 W. 80th Place Suite A
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:
   

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:

How were you referred to us?


 

Comments:

NOTE: Submit a copy of your operative report to expedite the scheduling of your procedure. Please hit 'Submit' ONCE as this will come directly to our email address.

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