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MHB South 2021 Consultation Request Form

Part 1: Personal details

PLEASE NOTE:  The MHB South 2021 Virtual Conference is Saturday, February 27, 2021.  
This conference will present specific information from providers in the southern part of the United States.  MHB had hoped to launch one-day regionally focused conferences in 2021 starting with MHB Florida and MHB Texas.  However, with ongoing health concerns and travel restrictions, we've decided to offer an alternative that anyone can attend.   The event was planned for Saturday, February 20, however, the severe weather conditions and aftermath in Texas has led to a one-week delay so that Texas-based providers and Intended Parents can attend. 

Individuals who already registered for our MHB South 2021 may use this form to request a private consultation with one or more providers who will be available before and following the conference on February 20, 2021.

Your information will remain confidential and only shared with the service providers you indicated (but first you will receive a confirmation email to verify that you indeed submitted this request).

1. Prospective parent #1Please provide full legal name.
This question requires a valid email address.
Do you identify as: *This question is required.
2. Do you plan to have children as: *This question is required.
Prospective parent #2 *This question is required.Please provide full legal name
Are you legally married?

With which of the following agencies and / or clinics would you like to request a private consultation? *This question is required.* Asterisk denotes a member of the MHB Advisory Circle
How did you have your previous children (check all that apply)?
If you already have children through surrogacy, don't forget to fill our MHB Parent survey!
4. What type of surrogacy are you pursuing / considering?
5. Languages you (or your partner) speak: