Your Name (required):
    Address (required)
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    Province (required)
    Postal Code (required)
    Phone - Home
    Phone - Other
    Email (required)
    For which session are you registering?
    How did you hear about Conceivable Options?
    Is it OK to leave a message at your home phone? yesno
    Date of Birth
    Are you dealing with primary or secondary infertility? primarysecondary
    If secondary, how many children do you have?
    Partner's name, if applicable
    Are you undergoing fertility treatment? yesno
    If yes:
    Facility Name:
    Doctor Name:
    Doctor Address:
    Payment Options ChequePaypal
    "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."