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Pregnancy Verification Form
Please send completed form to GBG Administrative Services, Inc.

Online submission: www.gbg.com

Submit: [email protected]

Mail: 27422 Portola Parkway #110 Foothill Ranch, CA 92610
A. PATIENT INFORMATION
Name (Last, First, MI):
Member ID #: 999-

Member Date of Birth (DD/MMM/YYYY):

Date of your last menstrual period (DD/MMM/YYYY):

Date of your initial OB/GYN consult (DD/MMM/YYYY):

Name and address of your treating OB/GYN:

Is this pregnancy the result of receiving any procedures to enhance fertility, stimulate hormones, stimulate
ovulation or stimulate egg production or correct menstrual irregularities? Yes No
Is this pregnancy the result of receiving any procedures or exams to monitor egg production or growth, to harvest
ovum/eggs, and/or
implantation of any human tissue or
Yes
No
cells?
Have you ever received fertility or infertility
No
treatments? Yes
If yes, please indicate the type of treatment received, including the names of medications t