Surrogate Intake Form
Thank you for taking the time to complete the Surrogate Intake Form. Gestational Surrogacy is a very personal journey, and this Intake Form will help Paying It Forward Surrogacy, LLC (PIFS) know about you, your pregnancy and births.This is also your chance to provide PIFS with criteria for a potential Intended Parents (including where the Intended Parents lives, views on termination for medical necessity, desire for a Single vs. Double Embryo Transfer, and the type of relationship you would like to maintain during and after your journey).
Personal Information
Full Name
*
First Name
Last Name
Date of Birth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Profession
Type a question
Partner Name
Partner Date of Birth
Partner Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Partner Phone Number
-
Area Code
Phone Number
Partner email address
example@example.com
Partner current job
Current Insurance
Have you ever been a gestational surrogate before?
Desired base compensation
Medical Information
Current weight and Height
Number of Pregnancies
Number of Live births
Number of Abortions
Number of Miscarriages
Date of live births
Last Menstrual cycle date
Number of C-sections
Did you have gestational diabetes in your previous pregnancy or pregnancies
Yes
No
Do you have a history of pre-term labor, birth or bedrest?
Yes
No
Check the conditions that apply to you or to any members of your immediate relatives:
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Not Applicable
Type a question
Are you currently taking any medication?
*
Yes
No
If YES please describe
Do you have any medication allergies?
*
Yes
No
Not Sure
Do you use or do you have history of using tobacco?
*
Please Select
Yes
No
Do you use or do you have history of using illegal drugs?
*
Please Select
Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Additional Medical Questions
Would you be open to terminating a pregnancy if severe medical issues were discovered (for example, severe genetic issues, would not survive or would have a poor qualify of life)?
Yes
No
Would you be open to selective reduction of a pregnancy for multiples greater than a twin gestation?
Yes
No
Are you currently breast feeding
No
Yes
If currently breast feeding, how long have you been breast feeding?
If breast feeding, when do you plan to stop breast feeding (please include month and year)?
Relationship with Intended Parents
Please describe your ideal relationship with your Intended Parent(s):
Please describe how frequently you would like to communicate with your Intended Parent(s):
Miscellaneous Questions
Ideal location of Intended Parent(s)
Available for travel for medical screening and embryo transfer?
Yes
No
Are you open to a hospital birth
Yes
No
Essay Questions
How did you first find out about surrogacy?
Why do you want to be a gestational carrier?
How does your family feel about you being a gestational carrier?
Tell us a little about your own pregnancies/births.
Submit
Should be Empty: