Birth Report Form

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:*
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
HIPAA Compliance
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