Pregnancy Report

First Name

Last Name (at time of surgery)

Last Name (current)

City

State

Country

Date of Reversal

We of Dates

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

How May We Contact You?

Email Address

Work Phone

Cell Phone

Home Phone

Please enter additional information or comments

Email