IIRRM - The International Institute of Restorative Reproductive Medicine

Members Only Log In

Not a member, apply now

Forget your username or password?

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 *		Initial Renew

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.		Paypal (Free and Secure online payment with charge or debit, paypal account not required) Mail in (Fee applies)

Type of Member or non-member affiliation* - Please read descriptions of membership types and choose the category that best describes you.		Member - Medical personnel providing clinical services in restorative reproductive medicine OR professional researchers actively involved in related research, £100 (pounds Sterling) per year. Associate - Other individuals or organizations who share in the goals of IIRRM, £100 (pounds Sterling) per year. Student - Currently enrolled in a health-related or research-related professional school at the graduate level, £25 (pounds Sterling) per year. Supporter - 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, £100 (pounds Sterling) per year.

First name*		Last name*


Sex		Male Female

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.
Yes No

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
Yes No

Do you carry malpractice insurance?
Yes Not Applicable No

Have you completed an NPT medical consultant course? If yes, where NPT training course was conducted
Yes Not Applicable No
Date of completion Month XX, XXXX

Are you certified as a FertilityCare Medical Care Consultant?
Yes Not Applicable No
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, Female Yes, Male No

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. *
Yes No

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. *
Yes No

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.