Registration Form for Personal Consultation

The Pregnant Traveler Medical Services, PLC

Please fill out the form below to contact us with your comments and questions. Please note that in order to reply specific questions regarding your pregnancy or your trip we will need detailed information about our health history and your itinerary.

There is a consultation fee charge for providing answers to specific questions regarding your situation.

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First Name
Last Name
Address
City
State of Province
Zip or Postal code
Country
Phone
Fax
Are you pregnant now?
Are you away from home now?
Name of your obstetrical provider
Address & Telephone of provider
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Please include, if possible, fax # and email address.

Do you wish us to send a copy of our consultation to your provider?
Comments
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