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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Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Date of Birth
Current Insurance Provider
Type of Insurance
Brief Medical History
How old were you when 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):
If none, enter 0.
Number of previous laparotomies (bikini incision):
If none, enter 0.
How can we help you?
Summary of Medical History
Do you think you will need surgery?
- Yes
- No
- Unsure
Are you considering coming to see Dr. Cook?
- Yes
- No
- Undecided
Approximate date you are considering coming to Vital Health Endometriosis Center:
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Summary

Article Name

Review My Case

Description

Do you suffer from endometriosis even after multiple surgeries? Request a free record review and phone or Internet consult with Dr. Cook and see what he can do for you.

Brief Medical History