Intended Parents Application
Full Name of Intended Parent 1
*
Gender of IP 1
*
Full Name of Intended Parent 2
Gender of IP 2
Date of Birth of Intended Parent 1
*
Date of Birth of Intended Parent 2
Home Address
*
Email Address of IP 1
*
Email Address of IP 2
Phone Number of IP 1
*
Phone Number of IP 2
Languages you speak
*
What is the Occupation of IP 1
*
What is the Occupation of IP 2
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Are you using your own genetics or donor?
*
Are you working a Reproductive Endocrinologist?
*
Yes
No
What is your IVF Doctors Name?
What is your IVF Clinics Name?
Do you have any other children?
Are either of you Hepatitis B carrier?
*
Yes
No
Are either of you HIV carrier?
*
Yes
No
How long have you been planning to have a baby?
*
What have you chosen Surrogacy?
*
Do you already have embryos created?
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Yes
No
How many embryos are you wanting to transfer per transfer?
*
Are your embryos PGS/PGD tested?
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Yes
No
Will gender selection on the embryos be completed?
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Yes
No
If you discover the fetus has physical abnormalities, would you want to terminate the pregnancy?
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Yes
No
If it is a multiple pregnancy, would you want to have selective reduction performed?
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Yes
No
If you discover the fetus has Down syndrome, would you want to abort the pregnancy?
*
Yes
No
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What type of relationship, would you like with the Surrogate, during the pregnancy?
*
What type of relationship would you like with the Surrogate, after the delivery?
*
What would you like to tell the surrogate about yourself? (Story of Infertility, your likes and interests, How you met, (If applicable) Etc.)
*
Do you have a medical condition that is threatening your life?
*
Yes
No
Are you taking any medication(s) at the moment?
*
Yes
No
Do you have any health problems (diabetes, blood pressure, HIV, STDs, CMV, HepB, HepC, etc. )?
*
Yes
No
Do you have support from your family and friends?
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Yes
No
Do you want to be in the delivery room when your child is born?
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Yes
No
If you can’t be there for the birth, would you like photos taken?
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Yes
No
Would you like the surrogate to pump her breast milk and send it to you?
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Yes
No
What are your requirements for a Surrogate?
*
Which state would you prefer the Surrogate to reside at?
*
What message would you like to send to your Surrogate?
*
Signature
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