Tubal Reversal Experts
Medical and Anesthesia History
Please complete this form and fax it to (727) 796-8764. This medical and anesthesia history form must be submitted to us via facsimile. Once you complete the form click your web browsers print button and fax this form to us.
Please call us at (866) 882-2573 if you have any questions.
Please be sure the form is complete and accurate. This information is to ensure your health and safety when Dr. Edward Zbella or Dr. Mark Sanchez performs your tubal reversal surgery. Providing inaccurate information will result in your surgery being delayed or cancelled.