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Tubal Reversal Pregnancy Report Form

Congratulations! You're pregnant!

Please fill out this form once you receive a positive pregnancy test. Click the Submit button at the bottom of the form to send it to us.

First Name:
Last Name:  
City/State/Zip      
Home Phone:
Work Phone:
Cell Phone:
Email:
Date of your tubal reversal surgery
Date of last menstrual period
Date of positive pregnancy test
Predicted due date
Did you use any fertility medications with this conception? Yes            No
If so, what medications:
Additional comments: