Membership Application

Please use the following form to join the Institute or to renew your membership.
Fields marked with a * are required to fill in, in order to process the form.

See the bottom of the page for our privacy statement.

For Organizational Membership please contact us directly.

Membership Application
Type of Application *  
     
Type of Payment Preferred - You will be able to make this choice at a later time, however if you have already chosen please let us know. For more details see our membership page.  
     
Type of Member or non-member affiliation* - Please read descriptions of membership types and choose the category that best describes you.  

- Medical personnel providing clinical services in restorative reproductive medicine OR professional researchers actively involved in related research, $200 USD. (3 Year option available for $500, a savings of $100)


- Other individuals or organizations who share in the goals of IIRRM, $50 USD. (3 Year option available for $125, a savings of $25)


- Currently enrolled in a health-related or research-related professional school at the graduate level, $10 USD

- are professionals who support the IIRRM, have access to the Institute resources, however are not required to sign the Ethical Code, are not able to vote or participate in research protocols, and are not listed on our member directory, $200 USD.

     
First name*   Last name*
 


     
Sex  
     
Date of birth Month XX, XXXX   Country of Practice*
 
 
Languages Spoken Fluently
 
Mailing address for IIRRM Correspondence*
     
E-mail for IIRRM Correspondence*   Phone number for IIRRM Contact *
 
     
E-mail for Patient Contact   Phone number for Patient Contact
 
     
Website Address   Fax work include country/area code
 
     

Please select information you wish to have available to patients on our website clinical directory.

 

  

E-mail for Patient Contact

Phone number for Patient Contact

Website Address
     
Please enter a couple of sentences to be placed with your listed on our directory.  
     
     
Present position & other relevant titles
     
Are you currently a health profession student? If yes please provide name of program, institution and type of degree being sought.

 
     
Clinical Licensure (If not applicable please put na in type of license)
Date received / renewed Month XX, XXXX  
Expiration Date Month XX, XXXX  
Type of Licensure and issuing authority  
     
Are you trained in a specialty? If yes please provide information on type of certification

 
     
Do you carry malpractice insurance?
Not Applicable
   
     
Have you completed an NPT medical consultant course?
If yes, where NPT training course was conducted
Not Applicable
 
Date of completion Month XX, XXXX  
     
Are you certified as a FertilityCare Medical Care Consultant?
Not Applicable
   
Date Certified Month XX, XXXX  
Expiration Date Month XX, XXXX  
Issuing Authority  
     
Relevant Training Clinical and Research
     
Main fields of work (check all that apply)

Family Practice

General Practice

Obstetrics & Gynecology

Endocrinology

Urology

  

Nursing

NFP, NPT, or related research

Research other

Medicine other

Surgery other

 
Please outline in order which of the following categories of patients you see in your clinical practice, from the most frequent to the least, considering the top five categories only.

1.

2.

3.

4.

5.

     
Does your practice include major reproductive surgery?
Yes, Male
   
 

Please provide a brief written description of how and why you have incorporated a restorative or cooperative approach to reproductive health in your practice.
 
Please review the Institute Code of Ethics. In applying for membership or renewal of membership, I hereby pledge to abide by the Code of Ethics as long as I am a member of the Institute. *
     
I certify that the above information is complete and correct to the best of my knowledge. During my membership in the Institute, I will maintain appropriate copies of all stated certifications and credentials noted in this application in my files, and provide them upon request to the Institute. *

   
     
Additional Comments    
 

Privacy Statement: The data you send us with the above form will only be used internally by IIRRM and will never be given to any person or organization outside IIRRM, unless it is a lawful or jury obligation.

Your name and e-mail address will only be used so we can contact you with reference to your application.

 

 
Available to Members and Associates