Membership Registration

The Smart Stork Membership

First Name:* First Name Required

Last Name:* Last Name Required

Address Line 1:* Address Line 1 is Required

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City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Username:* Username is Required

Email Address:* Email Address is Required

Date of Birth:* Date of Birth is Required

Hour of Birth:* Hour of Birth is Required

Last Period Date (LMP):* Last Period Date (LMP) is Required

Usual Cycle Length:* Usual Cycle Length is Required

Cycles:* Cycles is Required

Number of Previous Pregnancies:* Number of Previous Pregnancies is Required

History of Miscarriage:* History of Miscarriage is Required

Number of Miscarriage or Stillborn:* Number of Miscarriage or Stillborn is Required

Number of Children Born:* Number of Children Born is Required

Number of Boys:* Number of Boys is Required

Number of Girls:* Number of Girls is Required

Number Years Trying to Conceive:* Number Years Trying to Conceive is Required

Number of Months trying to Conceive:* Number of Months trying to Conceive is Required

Have You Ever Been Pregnant with Twins?:* Have You Ever Been Pregnant with Twins? is Required

Ever had an Ectopic Pregnancy?:* Ever had an Ectopic Pregnancy? is Required

Currently Having Fertility Treatments (IVF or Fertility Medication):* Currently Having Fertility Treatments (IVF or Fertility Medication) is Required

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Description	Amount
Smart Stork Membership – Payment	$599.00
Total	$599.00

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