Birth Report Form

Item: A Personal Choice
Rating: 5
Author: Dr. Monteith

First Name*
Last Name (at the time of surgery)*
Current Last Name (if changed)
Partners Name
Date of your tubal reversal
Month
Day
Year
Date of baby's birth
Month
Day
Year
Baby(ies) name(s)
Baby(ies) gender
- Male
- Female
- Both (Twins+)
Your current age*
Ligation Method*
Email*
Cell or home phone
Please provide an address for us to mail your baby's t-shirt
Please provide an address for us to mail your baby's t-shirt

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
We love photos of our reversal babies! Please attach a photo (max file size 5 mb). Contact DrMonteith@tubal-reversal.net if you are having difficulty.
Max. file size: 50 MB.
Please enter additional information or comments here:*
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To protect your privacy we will only publish your comment, age, type of tubal ligation reversed, and city and state.
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