Pregnancy Report

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First Name

Last Name (at time of surgery)

Positive of Performed

Last Name (current)

City

State

Country

Date of Reversal

Doctor Who Performed Surgery

Date of Last Menstrual Period

Date of Positive Pregnancy Test

Due Date

Number of Pregnancies Since TR

Outcome fo Previous TR Pregnancies and Dates

Type of Tubal Ligation

Email Address

Work Phone

Cell Phone

Home Phone

Please enter additional information or comments