Book Appointment Form

1. Please tell us who you are.

Your Name, Initials or Pseudonym*:

Your Contact Email*:

Your Contact Phone Number:

Name (if known) of expert you want to talk with:

Question you want to ask:

2. About You (please mark all that apply)










Marital Status


 In Relationship


Sexual Orientation






3. Where do you live?




4. Which services are you the most interested in? (please mark all that apply)


 Adoption -- Domestic

 Adoption -- International

 Alcohol cessation

 Chinese Medicine/Herbs


 Couples Counselling

 Egg Donation

 Egg Freezing

 Fertility Coaching

 Financial Planning

 Environment Cleanse

 Embryo Adoption/Donation





 Legal Planning

 Life Coaching

 Male Infertility Treatment



 Mind-Body-Spirit Therapies

 Nutrition and Diet

 Organic Food/Products


 Positive Visualization

 Single Parent By Choice

 Smoking cessation

 Sperm Donation

 Sperm Freezing

 Support Group





5. If you can go to Fertility Planit LA 2014, then meet experts in person for a free consultation. Let us know the best date and time and we will set up meetings for you.

 Meet Friday, April 4th

 Meet Saturday April 5th

 Morning between 9AM-1PM

 Afternoon between 1-5PM

6. Briefly state the reason for booking an appointment, and any questions, concerns or topics you'd like to talk about.

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