whitley-1 - Lakeshore Tubal Reversal Center

First Name *

Last Name (at time of surgery) *

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

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