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Tubal Reversal Online Registration

Dr. D. Dafashy and the nursing staff at The Southwest Center will review your information to determine if you are a candidate for Tubal Reversal surgery. Once it is determined that you are a candidate for the tubal reversal surgery, our staff will arrange your appointments.

If you require any assistance in getting started, please call our office at 713-790-0099 and we will be happy to assist you.

Full Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Best time for us to call you*

E-mail*

example@example.com

Date of Birth*

MonthDayYear

Weight & Height*

Name of hospital where your Tubal Ligation surgery was performed:*

City where hospital is located*

Year your ligation surgery was performed*

Last Name at that time*