Please provide the following information to help with your registration:

Name

Address

City

Province

AB BC MB NB NL NS NT NU ON PE QC SK YT

Postal Code

Phone

Cell Phone

Email

For which session are you registering?

How did you hear about Conceivable Options?

Is it OK to leave a message at your home phone?

Yes      No

Date of Birth

Are you dealing with primary or secondary infertility?

Primary    Secondary

If secondary, how many children do you have?

SELECT 1 2 3 4

Partner's name, if applicable

Are you undergoing fertility treatment?

Yes      No

 If Yes:      Facility Name

Doctor Name

Doctor Address

Payment Options

Cheque    Paypal

 
"I/we understand that the services and consultations provided by Conceivable Options are informational and educational.  They are not medical treatment or a substitute for professional medical advice that is provided by a licensed medical doctor.  In no way will Conceivable Options be held liable for any decisions made or action taken by me as a result of, or subsequent to, the above mentioned services/consultations."

We take your privacy seriously and will not share or distribute your contact information with any other party.