Thank you for making your appointment!

    We would like to get some information regarding your health history so we can better prepare for your surgery.  Please fill out the form below in its entirety.  If you are unsure of the information, please answer as best as you can.  If you are a wife filling this out for your husband, it is better to have him fill it out himself.  Please send him the link that came in your confirmation email which will bring him directly to this page.

    You can also email our office directly at kathy@midwestvasectomyreversals.com with questions.