Booking Form

PERSONAL DETAILS:
Name:
Address:
Postcode:
Telephone:
Home:
Mobile:
Work:
Email:
MEDICAL HISTORY:
Have you been diagnosed with any of the following?
	Unexplained Infertility
	Anovulation
	PCOS
	Endometriosis
	Low Sperm Count
	Poor Sperm Motility
	Immune System problems
	Other
Are you currently taking any medication?

Have you had any fertility treatment?

Do you/have you ever suffered from any mental illness?

I would like to attend:
Self Hypnosis for Fertility on Saturday 7th June 2008 10am-5pm
Self Hypnosis for Fertility on Saturday 16th August 2008 10am – 5pm
Self Hypnosis for Fertility on Saturday 15th November 2008 10am – 5pm
PAYMENT:
I would like to pay £120 for one person
I would like to pay £200 for a couple


If you would like to book online, please click the 'Pay by Paypal' button which will automatically sumbit your form and then take you to the Paypal Website to make your payment. If you would like to pay by cheque, please click the ''Pay by cheque' button which will allow you to print out your completed booking form. Please send the completed form to: Calmer Centre ltd, No 8, 36 York Street, London, W1H 1FF. Make all cheques payable to 'Calmer Centre ltd'.