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Review My Case

If you have a single question please click here, for the contact us 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.

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 these symptoms?

Pelvic Pain
During period
During ovulation
All the time

General Information
Pain w/ bowel movement
Gas
Constipation
Gas
Bloating
Diarrhea

Urinary
Urinate very frequently
Lose urine
Wake up to urinate at night
Find it difficult or painful to urinate

More
Leg Pain
Back Pain
Infertility

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. Seckin?*

Yes
Undecided
No

Approximate time you are considering coming out:



Type of Insurance


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


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