HelpBuildtheNetwork!

The CPTwomen Physician Referral

The CPTwomen is undertaking the task of putting together a Physician Referral List for PTwomen. We are asking all women to help us build a network of health professionals who we can refer to.

Directions:
1. Chose doctors in your local area that you would like the following invitation (below) sent to. This may be a doctor you know personally, someone who you have been referred to or someone from the telephone book.
2. Complete the form below with the doctors' name telephone and fax, then submit form to the CPTwomen. Only one name per submittal. You will need to complete this form for each health care professional you would like to be invited.

The CPTwomen will fax/forward the invitation direct to the doctor and will list the doctors' name at the CPTwomen Members' Site as having been formally invited. When the CPTwomen receives notice back from the doctor as having accepted the invitation, their name will be moved over to the referral list.

Send invitation to:

Doctors First Name:

Doctors Last Name:

City

State

Telephone #

Fax #

Field of medicine doctor specializes in:

General Practitioner, GP (family doctor)
Gynecologist
Internist
Endocrinologist
Other:

Invitation to be Placed on Patient Referral List

Dear Medical Professional,

The Coalition for Post Tubal Women (CPTwomen) is a national organization. Our mission is to educate and assist women. We are currently building a support network for post tubal women in their quest for proper and altruistic follow-up care.

Your name and contact information was provided to us by a woman who resides in your local area and who is seeking professional health care, guidance, and consultation. She wishes to retain a doctor who is able to state that tubal ligations can have side effects.

We would like to invite you to be listed in our private network of medical professionals who recognizes post tubal syndrome (PTS), is philanthropic, and is willing to help women confront the physical, hormonal, and mental issues of being post tubal.

To be included on our growing referral list please sign below and fax back to 815 328-0445.

Yes. Please include me on the list for patient referals.

Print Name __________________________

X Signature__________________________ Date_____________

Special instructions or other information to be included with listing:
(Attach additional pages if necessary)
_____________________________________________________

_____________________________________________________