Review My Case

After reviewing our Cost & Insurance Coverage page, Submit this form to have Dr. Seckin review your case. Please complete all sections. When you have completed the form, click on the "SEND" button at the bottom of the page.

If you have any questions please click here, for the contact us page.

All fields with * are required.



I am interested in scheduling surgery with Dr. Seckin*

I am a current patient of Dr. Seckin*.

I want my case reviewed by Dr.Seckin

Date of Birth

Do you have any of the following symptoms?

General

Dysmenorrhea (abnormal painful periods-menstrual cramps)
Menorrhagia (abnormal heavy menstrual flow)
Dyspareunia (pain upon sexual intercourse)
Pelvic pain

Bowel

Pain with bowel movement
Constipation
Diarrhea
Bloating
Gas

Urinary

Urinate frequently
Urinary retention (lose urine)
Wake up to urinate at night
Dysuria (difficult or painful to urinate)

Other

Leg pain
Back pain
Chest pain
Shortness of Breath
Infertility

What was the timing of your symptoms?

The onset of your symptoms (pelvic pain, etc.)

During period
During ovulation
All the time

How frequent are your symptoms?

Intermittent (on and off)
Waxing and waning (always on, but on and off in terms of worsening)
Worsening
Constant

How old were you when your symptoms first started?


How long have your symptoms persisted?

weeks
months
years
+5 years
over a decade

Date you were surgically diagnosed with endometriosis or adhesions (leave blank if not applicable)?


Number of laparoscopies (belly button incision):


Number of laparotomies (bikini incision):


Personal input section

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. Seckin?*

Yes
Undecided
No

Approximate time you are considering coming out:


Insurance

Type of Insurance


Please let us know what time is best for us to call you.


How did you hear about us?

Online Research
Social media (Facebook, Instagram, etc.)
Endometriosis Foundation of America
Relative or friend who was a patient
News article
Others

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