Request a Surgical Consult

Endometriosis &
Pelvic Pain

Minimally Invasive Surgery

Fibroids & Abnormal Bleeding

Adhesions

Interstitial Cystitis

Pain Management

Menopause

Nutrition & Lifestyle Therapy

Integrative Medicine

Routine Gynecology

Request a Surgical Consult

Submit this form to have Dr. Cook's office call you to set up a surgery, out of state initial telephone consult with Dr. Cook or a local new patient office appointment.

For those calling from outside of the United States or Canada, please email Michelle Waterstreet directly about your case and/or questions, and she will communicate with you about becoming a patient of Andrew Cook, MD.

This is a secure web page. This form uses an advanced security configuration system. The information you submit will be encrypted for your protection.

* = Required field

I am interested in scheduling surgery with Dr. Cook*
Yes
No
I am a local patient and am interested in setting up a new patient office appointment with Dr. Cook*
Yes
No
I am an out of state patient and am interested in setting up a phone consult with Dr. Cook*
Yes
No
I am a current patient of Dr. Cook*
Yes
No
First Name*
Last Name*
Address
City
State
Zip Code
Country
Work Phone Number*
 -  - 
Home Phone Number
 -  - 
Cell Phone Number
 -  - 
Which number do you want us to use first?*
Email Address*
Retype Email Address*
Name of Insurance Company
Type of Insurance
Date of Birth
 /  / 
How old were you when your symptoms first started?
If endo or adhesions, date you were surgically diagnosed:
 /  / 
Number of laparoscopies (belly button incision):
Number of 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 time you are considering coming out:
 / 

back to topback to top

Related Content