When filling out this form, please note the following:
  • Fields marked with a *red star are required.
  • The conference requires payment in order to attend. There are a number of price options, please pick one of them. You can pay either by credit card or by using another method as indicated below. Please indicate which of these two options you will use.
  • After submitting this page, you will see a summary, including the total price if applicable. You can then either return to the first page to make changes or submit your registration. If you choose to pay by credit card, you will be asked for your credit card information before the registration is finalized.

Personal information

*First name
*Last name
Title
(Mr., Ms, Dr. ...)
What you want to appear on ID Badge
e.g. Jane Doe, Event coordinator
Institution/Company
*Street address
*City
*Province/State
*Country
Postal/Zip Code
*Email
*Phone
Fax
Special requests
(e.g. dietary, accessibility, ...)

Payment method

*Please choose one of the following payment options
Credit Card
Other: Please make cheque payable to the University of Western Ontario and mail to 
Susan Badcock
Department of Obstetrics & Gynaecology
LHSC - VH, Room E3-620E

Registration information

*Please choose one of the following price options
Conference Registration - Physician/Researcher $100.00
Conference Registration - Allied Health $75.00
Conference Registration - Resident $0.00