Future Parent Profile
Intended Parent 1 Full Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Date Of Birth
-
Month
-
Day
Year
Date
Gender
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your occupation?
Intended Parent 2 Full Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Gender
Date Of Birth
-
Month
-
Day
Year
Date
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your occupation?
Are you working with a fertility clinic?
Please Select
Yes
No
If yes, please list the clinic’s name, doctors name and location.
Do you have any children?
Please Select
Yes
No
Have you collaborated with a surrogate in the past?
Please Select
Yes
No
Egg source for IVF?
Sperm source for IVF?
Do you have frozen embryos?
Please Select
Yes
No
If yes how many?
Will you have any Preimplantation Genetic Testing (PGT) on your embryos?
Please Select
Yes
No
If the fetus has abnormalities or a life threating condition,would you prefer to terminate the pregnancy?
Please Select
Yes
No
If yes, please explain any specifics
Do you have a preference of a boy or girl?
Please Select
Yes
No
If yes, what is your preference?
How many embryos would you prefer to transfer?
If your surrogate is pregnant with multiples would prefer selective reduction performed?
Please Select
Yes
No
Reduce from Triplets to Twins?
Please Select
Yes
No
Reduce from Triplets to a Singleton?
Please Select
Yes
No
Reduce from Twins to a Singleton?
Please Select
Yes
No
Intended Parent 1: Are you receiving treatment for any medical conditions?
Please Select
Yes
No
If yes, please explain:
Intended Parent 2: Are you receiving treatment for any medical conditions?
Please Select
Yes
No
If yes, please explain:
Intended Parent 1: Are you taking any prescriptions?
Please Select
Yes
No
If yes, please explain:
Intended Parent 2: Are you taking any prescriptions?
Please Select
Yes
No
If yes, please explain:
Intended Parent 1: To the best of your knowledge do you have any of the following conditions? (HIV, Hepatitis A,B or C)
Please Select
Yes
No
If yes, please explain the duration and treatment?
Intended Parent 2: To the best of your knowledge do you have any of the following conditions? (HIV, Hepatitis A,B or C)
Please Select
Yes
No
If yes, please explain the duration and treatment?
What languages do you speak?
Do you speak English?
Please Select
Yes
No
Do you need a translator when speaking with the attorney or psychologist?
Please Select
Yes
No
Please provide a brief bio of yourself (selves)?
Please explain why you have chosen to grow your family through surrogacy.
Please describe what type of relationship you would like with your surrogate.
Do you plan to attend the OB/GYN doctor appointments with your surrogate?
Please Select
Yes
No
Would you like to be in the delivery room during the birth?
Please Select
Yes
No
If you cannot make the birth of your baby, would you like photos to be taken?
Please Select
Yes
No
Submit
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