Nikeya-Clark1-768x1024 - Lakeshore Tubal Reversal Center

Testimonial Submission

Pregnancy Report

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 *

How May We Contact You?

Email Address *

Work Phone

Cell Phone

Home Phone

Please enter additional information or comments

Name