IP application Form

1

What is your family structure* This field is required.

married Heterosexual couple

Domestic partners (unmarried couple living together)

Same‑sex couple

Single Father

Single Mother

3

Intended Parent 1 Name* This field is required.

First Name

Last Name

4

Date of Birth* This field is required.

Date

5

Gender* This field is required.

MaleFemale

6

Blood Type* This field is required.

7

Citizenship* This field is required.

8

Country/State of Residence* This field is required.

9

Occupation：* This field is required.

10

What languages do you speak?* This field is required.

11

Phone Number* This field is required.

Country Code

Area Code

Phone Number

12

Email* This field is required.

example@example.com

13

Person other than spouse to be notified in case of emergency:* This field is required.

14

Address* This field is required.Please fill out correct and full address,not only list city and country

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

15

Intended Parent 2 Name* This field is required.

First Name

Last Name

16

Date of Birth* This field is required.

Date

17

Gender* This field is required.

MaleFemale

18

Blood Type* This field is required.

19

Citizenship* This field is required.

20

Country/State of Residence* This field is required.

21

Occupation：* This field is required.

22

What languages do you speak?* This field is required.

23

Phone Number* This field is required.

Country Code

Area Code

Phone Number

24

Email* This field is required.

example@example.com

25

How long have you been together ?* This field is required.

26

Do you have any children?* This field is required.

YESNO

27

If yes, please list ages,gender and whether they were born via IVF, surrogacy, or natural birth.* This field is required.

28

Reason for pursuing surrogacy* This field is required.

Infertility diagnosis

Medical condition

Same‑sex couple

Single parent

29

Have you undergone IVF to get pregnant by yourself before?* This field is required.

YESNO

30

Do you need donor eggs?* This field is required.

YESNO

31

Do you need donor sperm?* This field is required.

YESNO

32

Do you currently have embryos?* This field is required.

YESNO

33

Number of embryos* This field is required.Please specify the total number of embryos and, if available, provide a detailed breakdown by sex

34

PGT‑A tested? * This field is required.

YESNO

35

Please indicate the development day of your embryos:* This field is required.

Day 3

Day 5 (blastocyst)

Day 6 (blastocyst)

36

Frozen at which clinic?* This field is required.

37

Please list an email contact for your fertility clinic.* This field is required.

38

What is the name of the fertility doctor you are working with?* This field is required.

39

Are you or have you ever been positive for any of the following things? If yes please list what specifically. HIV, Hepatitis A,B,or C or any STDs* This field is required.

40

What is your preferred surrogate age range?* This field is required.Example: 23–35

41

Surrogate location preference* This field is required.

California

Nationwide

Specific states

No preference

42

Please list which state * This field is required.

43

Accept a surrogate with previous C‑sections?* This field is required.

YESNO

44

Prefer a surrogate who does not work during pregnancy?* This field is required.

YESNO

45

Prefer surrogate with stable home environment?* This field is required.

YESNO

46

Prefer surrogate with flexible schedule?* This field is required.

YESNO

47

Do you have diet preference during pregnancy?* This field is required.

YESNO

48

If yes,what is your preference* This field is required.

49

Communication Preferences* This field is required.

Weekly updates

Monthly updates

Only major medical updates

Prefer text messages

Prefer video calls

No preference

50

Relationship Style With Surrogate* This field is required.

Close relationship (frequent communication)

Moderate relationship (regular updates)

Prefer minimal contact

No preference

51

Prefer surrogate to follow specific OB/GYN guidelines?* This field is required.

YESNO

52

Prefer surrogate to avoid heavy lifting?* This field is required.

YESNO

53

Prefer surrogate to avoid travel during pregnancy?* This field is required.

YESNO

54

Comfortable with surrogate delivering in her local hospital?* This field is required.

YESNO

55

Prefer surrogate who is open to selective reduction?* This field is required.

YESNO

56

Prefer surrogate who is open to termination for medical reasons?* This field is required.

YESNO

57

Prefer surrogate with previous surrogacy experience?* This field is required.

Yes

No

No preference

58

Prefer surrogate with strong support system ?* This field is required.

YESNO

59

Prefer surrogate who is married?* This field is required.

Yes

No

No preference

60

Prefer surrogate with stable income ?* This field is required.

YESNO

61

Prefer surrogate who is open to termination for medical reasons?* This field is required.

YESNO

62

Prefer surrogate who is comfortable with intended parents attending appointments?* This field is required.

Yes

No

No preference

63

Prefer surrogate who is comfortable with intended parents being present at birth?* This field is required.

Yes

No

No preference

64

Will you transfer more than one embryo?* This field is required.

YESNO

65

Please list the attorney you are working with* This field is required.

66

Please list the Attorney's Email address below.

67

Do you have a translator?* This field is required.

YESNO

68

Please list the name of your translator* This field is required.

69

Please provide translator email

70

Are you prepared for the possibility of a failed embryo transfer?* This field is required.

YESNO

71

Are you willing to attempt multiple cycles if needed?* This field is required.

YESNO

72

Are you emotionally prepared for the full surrogacy journey? * This field is required.

YESNO

73

Are you able to handle potential delays or medical risks?* This field is required.

YESNO

74

Please take this opportunity to write a letter to the surrogate who will be reviewing your profile* This field is required.

75

Please upload 4 pictures* This field is required.It doesn’t need to be a group photo; any photo works.

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