Pregnancy Report Form

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This field is for validation purposes and should be left unchanged.
First name*
Last name (at the time of the surgery)*
Current last name (if changed)
Number of pregnancies since reversal
Date of your tubal reversal
Month
Day
Year
Due date
Month
Day
Year
Outcome of other reversal pregnancies and dates
Ligation Method*
Your current age*
Email*
Cell or home phone
City*
State*
Please enter additional information or comments here*
Your comments are extremely important to us and to other couples considering tubal reversal. May we have your permission to place your comment on our website?

To protect your privacy we will only publish your comment, age, type of tubal ligation reversed, and city and state.
Permission to publish*
- Yes
- No

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Pregnancy Report Form

Enter to Win A Free Reversal Surgery!

Don’t miss your chance for the Harris Holiday Giveaway: FREE Reversal Surgery!

What Would You Like to Schedule?

Tubal Reversal Or Essure Reversal

Vasectomy Reversal

Pregnancy Report Form

Have a Question? Drop Us A Line!

Enter to Win A Free Reversal Surgery!

Don’t miss your chance for the Harris Holiday Giveaway: FREE Reversal Surgery!

What Would You Like to Schedule?

Tubal Reversal Or Essure Reversal

Vasectomy Reversal