Review My Case

Submit this form to request a free record review and phone or Internet consult with Dr. Cook. On receipt of your details we will get in touch with you to arrange the record review and schedule a phone or Internet consultation with Dr. Cook.

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Contact information

* = required field

First name *

Last name *

Street address

City

State

Zip/Postal code

Country

Phone *

Email *

Retype email address *

Name of insurance company

Type of insurance

Date of birth

Brief medical history

How old were you when your symptoms first started?

If you have an existing diagnosis of endometriosis or adhesions, please provide the date you were surgically diagnosed:

Number of previous laparoscopies (belly button incision):

Number of previous laparotomies (bikini incision):

How can we help you?

Summary of medical history

Do you think you will need surgery?
 Yes No

Are you considering coming to see Dr. Cook? *
 Yes Undecided No

Approximate date you are considering coming to Vital Health Endometriosis Center:

*