Infertility Family Research Registry: Clinic Registration
Primary Clinic Contact
Last Name
First Name
Contact Degree
Contact Role at Clinic Enter Other Contact Role  
Clinic Type
ART Clinic
     ART Clinic State (Canadian Territories and Provinces listed after states)
     ART Clinic Name    
     ART Clinic Other: (enter clinic name)  
Other Clinic (general ob-gyn, urology, other infertility)
     Clinic Name
    
Address line 1:
Address line 2:
City :
State:
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
Re-enter Email Address
Are you affiliated with an institution that has its own IRB?       
 
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