Fertility Well-Being Series - Registration - Acupuncture, Massage, Mindfulness, Traditional Chinese Medicine: Victoria

Welcome to the Fertility Well-Being program! Thank you for your time in completing this form so that I can provide a supportive learning experience. All information shared here will be completely confidential and will only be read by the me (Stephanie Curran)

Name*

First Last

Email*

Cell number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Profession*

How did you hear about this course? (please be as specific as possible)*

Please share a little about yourself, your fertility journey, and what brings you to this class at this time.*

Have you been pregnant before?*

Yes

Please share some details about any losses you have experienced.*

Do you have any living children?*

Yes

If you answered yes above, please share some details about your journey with growing your family and the age(s) of your child(ren). Note: For those with Secondary Infertility, a phone call will be scheduled with Stephanie prior to the first class to ensure this is an appropriate program for you. If you have any questions about this before proceeding with your registration, please email Stephanie to discuss (scurran@elementscentre.ca). Otherwise you can continue and she will reach out to you.*

Please check the box(es) that apply to you*

Briefly describe any other major stressors, worries or concerns in your life*

Do you have any questions or comments?

Fertility Well-Being Series

Price:

GST

$ 0.00 CAD

Total

Payment Method

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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Fertility Well-Being Series – Registration