Tubal Reversal Center LLC
Confidential Patient Intake
Patient & Partner Information
Patient name *
Patient DOB * (MM/DD/YYYY)
Partner name *
Partner DOB * (MM/DD/YYYY)
Address *
City *
State *
Zip *
Phone *
Email *
Pharmacy
Pharmacy name
Pharmacy address
Pharmacy phone
Patient History
1
Number of live births, miscarriages, and ectopic pregnancies
Live births
Miscarriages
Ectopics
2
Year of last childbirth
Patient
Partner
3
Patient weight & height
Weight (lbs)
Height (ft)
Height (in)
4
Are your cycles regular?
YESNO
5
Medical problems or conditions
6
Patient surgical history
7
Current medications
8
Allergies
9
Do you smoke or vape?
10
Do you or your partner use recreational drugs?
If yes, which drugs
How did you hear about us?
