Surrogate Registration Form
Name
First Name
Last Name
Current Partner Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (please add country code if outside Canada and USA)
Immigration Status
Canadian Citizen
USA Citizen
Canadian/USA Permanent Resident
Canadian/USA Work Permit
Canadian/USA Study Permit
Traveller to Canada/USA
International outside Canada and USA
Do you have insurance coverage other than the public health plan provided by provincial or territorial government
I have my provincial/territorial health card
No, but I have my Canadian university health coverage for international student or have medical insurace provided by my Canadian employer
No, but I have medical coverage in the USA
No, but I have international medical coverage I buy from international insurance company
No, I don't have any medical coverage
Which lanuages you can speak and can communicate
English
French
Chinese including mandarin and cantonese
Other
Emergency Contact Person Phone Number or Email
Surrogate Self Introduction
Please complete 5-6 sentences to introduce yourself and what are top reaons you would like to help the Intended Parents as surrogate:
Surrogate General Information
Profession
What is your current profession and current employer information? and Please also include your current partner information for name, profession and current employer information
Health
Have you ever been pregnant?
Is there a history of multiple births or complications for your past pregnancy or any one in your immediate family?
Do you have allergies?
Do you smoke? If yes, how many per day?
Do you drink alcohol? If yes, how many glasses per week?
Do you take recreational drugs? If yes, please explain.
Have you ever been treated for drug or alcohol abuse?
At time of past pregnancy, if there is any, were you taking any medication or supplements?
At time of past pregnancy, are you under the care of a physician or high risk OB? If so, for which reason?
Personal
How do people describe you? What are your main personality traits?
What are your hobbies and interests?
What are your expectations for future contact or relationship with child born through surrogacy?
What is your thought for termination due to fetus defect found during the pregnancy?
Motivation
Have you ever been surrogate? I so, was there a successful pregnancy? What is your motivation helping infertile Intended Parents?
Family Sexual Health
Sexual Health: Have you ever been diagnosed with any of the following?(You need to type No even though you never have any), if yes, please indiate youself or your partner
I do not have any infectious/sexual diseases:
Type option 1
Type option 2
Type option 3
Type option 4
Have you or any direct family member ever been diagnosed with any of the following? (You need to type No even though you never have any)
Any Child Born through your Past pregnancy or Surrogacy Journey
Child Demographic
Surrogate Family Picture
Surrogate Family Pictures (Please attached 5-10 high-definition pictures, if possible)
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