Application Form for Conception Chart

Please complete this Application Form carefully and submit to the authorised distributor closest to you. The company will assist you to complete this form should you require assistance. Your application is treated as confidential. Your CHOICE Conception Chart + Diet Recommendation will be sent to you within 12 working days from the date of acceptance of this Application Form by the company.

Application Form for Conception Chart

(Private & Confidential)

I am looking for:

Name *:

Email *:

Address *:

Profession *:

Identity Card No / Passport No *:

Mobile Telephone No *:

Blood Type *:

Date of Birth *:

Approximate age at which your first period occurred: * If you are unable to remember the year, please indicate whether it was between 12 or 13 or later

Average length of monthly period: (eg. 28 to 30 days):

Date of start of your last period: * Excluding spotting if you are currently on the pill please stop immediately and use another form of contraception

Are your periods regular or irregular: RegularIrregular

Approximately how long did you take to achieve your last conception (if applicable):

1
2
3
4

Do you take any medication to increase your fertility?: YesNo

Have you had any miscarriages/abortion/still birth?:

Number of all your children and their age?:

Child 1		years old
Child 2		years old
Child 3		years old
Child 4		years old

Where did you hear about the Choice Method?:

What magazine & newspaper do you read most?:

Who is your current Gynaecologist?:

I hereby apply for the Choice Conception Chart showing the favourable periods for the conception of a baby: Boy/Girl (strike out as applicable). I confirm that I will strictly observe and follow the Choice Conception Chart. I have read and understood the terms and conditions on the reverse and I agree to these terms and conditions. I confirm that information given by me in this form is true and correct.

All payments are to be made to ——

Credit Card Type:

Cash / Cheque No:

Chart Starting Month:

Remarks:

Husband name:

Identity Card No:

Mobile Telephone No:

Blood Type:

Date of Birth: