Infertility Family Research Registry: Clinic Registration
Primary Clinic Contact
Last Name
First Name
Contact Degree
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MD
DO
PhD
ARNP
RN
BSN
MSN
MSW
MBA
Other
Contact Role at Clinic
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Clinic Director
Physician
Nurse
Embryologist
Counselor
Other
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Clinic Type
ART Clinic
ART Clinic State
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ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
PUERTO RICO
ALBERTA
BRITISH COLUMBIA
MANITOBA
NEW BRUNSWICK
NEWFOUNDLAND/LABRADOR
NORTHWEST TERRITORIES
NOVA SCOTIA
NUNAVUT
ONTARIO
PRINCE EDWARD ISLAND
QUEBEC
SASKATCHEWAN
YUKON
(Canadian Territories and Provinces listed after states)
ART Clinic Name
Choose Clinic
ART Clinic Other: (enter clinic name)
Other Clinic (general ob-gyn, urology, other infertility)
Clinic Name
Address line 1:
Address line 2:
City :
State:
Choose
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
PUERTO RICO
ALBERTA
BRITISH COLUMBIA
MANITOBA
NEW BRUNSWICK
NEWFOUNDLAND/LABRADOR
NORTHWEST TERRITORIES
NOVA SCOTIA
NUNAVUT
ONTARIO
PRINCE EDWARD ISLAND
QUEBEC
SASKATCHEWAN
YUKON
OTHER
Canadian Provinces listed after states.
If outside US/Canada : Choose OTHER (at end of list)
Please enter country and other information needed for address outside of US/Canada
Zip (or Postcode)
Clinic Contact Information
Contact Phone Number
(
)
-
Ext
(xxx) xxx-xxxx
Contact Email Address
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Are you affiliated with an institution that has its own IRB?
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