Registration form
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Please copy this form to a Word or text file and mail it to me as an attachment to keesj@rdgg.nl . or fax it to +31.70.340.1173. After verification you will receive confirmation by fax.

REGISTRATION FORM

Identification data

Center: Contact person:

Center: Name:

Address: street:

Postal Code:

Po box

Postal code:

Town:

State:

Country:

Tel:

Fax:

e-mail:

Name Medical director:

Name Laboratory director:

Web site:

Approximate number of babies from blastocyst transfer so-far:

Preferred ID:

Preferred password:

 

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Disclaimer:This information is not intended as a substitute for medical advice of physicians. The reader should regularly consult a physician in matters relating to his or her health and particularly with respect to any symptoms that may require diagnosis or medical attention.

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