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Chicago 2018 Consultation Request Form

Part 1: Personal details

Individuals who already registered for our Chicago 2018 Conference may use this form to request a private consultation with one or more providers who will be available before and following the conference on April 14th & 15th 2018.

Your information will remain confidential and only shared with the service providers you indicated (but first you will receive a confirmation email to verify that you indeed submitted this request).

1. Prospective parent #1Please provide full legal name.
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This question requires a valid email address.
Do you identify as: *This question is required.
2. Do you plan to have children as: *This question is required.
Prospective parent #2 *This question is required.Please provide full legal name
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Are you legally married?


With which of the following agencies and / or clinics would you like to request a private consultation? *This question is required.* Asterisk denotes a member of the MHB Advisory Circle
How did you have your previous children (check all that apply)?
If you already have children through surrogacy, don't forget to fill our MHB Parent survey!
4. What type of surrogacy are you pursuing / considering?
5. Languages you (or your partner) speak: