Surrogate Mother Informed Consent Form
Personal Details
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Number
*
Voluntary Participation
Voluntary Participation Statements
*
I freely agree to act as a gestational surrogate
I have not been forced or pressured to make this decision
I understand that withdrawal before embryo transfer is subject to the applicable surrogacy agreement and law
Acknowledgement Signature
*
Comments or Concerns
Medical Assessment
Consent to medical examinations
*
Yes
Consent to infectious disease screening
*
Yes
Consent to psychological assessment
*
Yes
Consent to obstetric assessment
*
Yes
IVF Treatment
Consent to hormone medications used for IVF treatment
*
Yes
No
Consent to embryo transfer procedure
*
Yes
No
I acknowledge that embryo transfer may not result in pregnancy
*
I acknowledge
I acknowledge that multiple pregnancy is possible
*
I acknowledge
Pregnancy Risks
I acknowledge that miscarriage may occur
*
Acknowledged
I acknowledge that ectopic pregnancy may occur
*
Acknowledged
I acknowledge that hypertension may occur
*
Acknowledged
I acknowledge that gestational diabetes may occur
*
Acknowledged
I acknowledge that haemorrhage may occur
*
Acknowledged
I acknowledge that premature labour may occur
*
Acknowledged
I acknowledge that Caesarean delivery may become necessary
*
Acknowledged
I acknowledge that maternal death, although rare, is possible
*
Acknowledged
Medical Decision-Making
Acknowledgement
*
I retain the right to make decisions regarding my own healthcare during pregnancy
Intended parents may be consulted on medical matters but cannot override decisions necessary for my health
Emergency treatment may be provided if required to protect my life or health in accordance with applicable law and accepted medical practice
Healthcare Consultation
*
I understand that consultation may occur with the intended parents regarding my care
I understand my healthcare provider will make decisions based on medical necessity and accepted practice
I understand my personal health interests take priority in medically necessary decisions
Emergency Care Acknowledgement
*
I understand emergency treatment may be given when needed to protect my life or health
I understand such emergency treatment will be provided in accordance with applicable law
I understand that emergency medical decisions may be made without prior approval if immediate action is necessary
Delivery
Delivery arrangements discussed
*
Yes
Intended parents present where possible and appropriate
*
Yes
Legal parentage may require additional legal processes depending on jurisdiction
*
Yes
Confidentiality
Consent to Share Necessary Medical Information with Intended Parents
*
Yes
Acknowledgment of Confidentiality and Exceptions Required by Law or Treatment
*
Yes
Counselling
I confirm that I have attended counselling
*
Yes
I understand the emotional implications of surrogacy
*
Yes
I have had adequate opportunity to ask questions
*
Yes
Legal Advice
Have you received independent legal advice?
*
Yes
No
Reason for not obtaining independent legal advice
Final Declaration
Final declaration acknowledgements
*
I have read this document
I understand the medical and legal implications
My questions have been answered
I sign voluntarily
Signatures
Surrogate Mother Name
*
First Name
Middle Name
Last Name
Surrogate Mother Signature
*
Surrogate Mother Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Spouse/Partner Name
First Name
Middle Name
Last Name
Spouse/Partner Signature
Spouse/Partner Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Treating Physician Name
*
First Name
Middle Name
Last Name
Treating Physician Signature
*
Treating Physician Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Embryologist Name
First Name
Middle Name
Last Name
Embryologist Signature
Embryologist Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Witness Name
*
First Name
Middle Name
Last Name
Witness Signature
*
Witness Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Clinic Certification of Informed Consent
Clinic Name
*
Patient / Donor / Surrogate Name
*
Hospital Number
Procedure
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Certification Checklist
*
Identity verified
Procedure explained, including purpose, benefits, risks, alternatives, and limitations
Sufficient opportunity to ask questions and satisfactory answers received
Psychological counselling and independent legal advice offered where appropriate
Apparent understanding and capacity to make an informed decision
Consent given voluntarily and without coercion
Clinic Representative Name
*
First Name
Middle Name
Last Name
Clinic Representative Position
*
Clinic Representative Signature
*
Clinic Representative Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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