Tubal Reversal Update Form

* Indicates Response Required

First Name*
Last Name *(at the time of surgery)
Current Last Name (if changed)
Doctor who performed your surgery
  Dr. Greene Dr. Turner
Date of your tubal reversal (Ex:D/M/Y)
Ligation Type
Email Address*
Baby's Photo (max:5mb,jpg,jpeg,png)
Please enter additional information or comments*

Thank you for your comments, they are very important to us and to the other women and couple considering Tubal Reversal. May we have your permission to place your comment on our website?

Along with your comment we will include your first name, initial of your last name, and state or country.

If you would prefer to remain anonymous then we will not display your name.

Permission to Publish.*
 You may display my comment first name, initial of last name and state. You may display my comment and state but I would like to remain anonymous. Do not display my comment.
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