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Application Form

Basic Information of Intended Parent 1

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Date of Birth
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Your Age
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Please provide your general employment information.
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What is your nationality?
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What is Your Ethnicity?
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What is your Religion Preference?
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What do you like to do in your spare time? Do you have any hobbies?
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Your General Health Condition
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Do you have any noticable medical problems? (If yes, please explain)
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Do you smoke? If so, how often?
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Do you consume alcoholic beverages?If so, how often?
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Do you use illegal drugs?
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Have you ever been convicted of a crime (excluding minor traffic violations) in any state or country?
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Have you ever had any therapy with a psychiatrist or other mental health professional, or hospitalization, for a notable mental illness or addiction?
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Please specify your marriage status.
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Whose name will be on the vital records of the baby?
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Please specify if your situation is "Other"
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Please specify your marriage situation.
Years together if living with a partner; Year getting married; Year getting divorced if applicable.
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Basic Information of Intended Parent 2

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Do you want to use the same address given above?
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Date of Birth
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Your Age
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Please provide your general employment information.
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What is your nationality?
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What is Your Ethnicity?
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What is your Religion Preference?
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What do you like to do in your spare time? Do you have any hobbies?
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Your General Health Condition
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Do you have any noticable medical problems? (If yes, please explain)
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Do you smoke? If so, how often?
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Do you consume alcoholic beverages?If so, how often?
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Do you use illegal drugs?
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Have you ever been convicted of a crime (excluding minor traffic violations) in any state or country?
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Have you ever had any therapy with a psychiatrist or other mental health professional, or hospitalization, for a notable mental illness or addiction?
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Common Information of IPs

If you are not a same-sex couple or single individual, what is causing your infertility?
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Have you already been medically or psychologically evaluated by any professional in the infertility field to undertake surrogacy or egg donation? when? If so, by whom and when
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Are you planning to find a Gestational Carrier to help you? If YES, please explain your reason.
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Do you have other children?
Please specify their gender and birthday.
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If YES to the above question, what is the main reason you want to have more children?
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Have you told them about your plans to have more children?
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Including yourself, how many people live in your home?
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Name and location of your current fertility center:
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Name of your IVF physician:
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Contact information of your case manager/nurse with the IVF clinic.
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If you already have frozen embryos, how many do you have?
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If you dont have embryos ready yet, how soon do you expect the embryos?
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Did you use or are you planning to use an egg donor/sperm donor?
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Do you expect support from family and friends?
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Are you concerned about what people might think or say about your working with Gestational Carrier?
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Do you understand that if your Carrier is required to travel, your clinic will require her to visit 1-2 days for screening, and again for 5-7 days approximately for the embryo transfer procedure?
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Do you understand that you may need to undergo a psychological evaluation prior to contracting with a gestational carrier?
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Will pregnancy termination be an option for you if the fetus is diagnosed high risk for chromosomal/genetic abnormalities?
Elaborate, if you choose no.
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Are you willing to undergo a criminal record background check upon request of the Carrier?
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If a pregnancy does not occur with your available embryos, do you intend to create more?
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How many embryo(s) do you want to transfer at a time?
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How much contact would you like with your Carrier during the pregnancy? Please elaborate.
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How much contact would you like with your Carrier after birth? Please elaborate
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Would you like the Carrier to provide breast milk for your baby, if she is amicable?
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What will you tell the child about the Carrier, if anything? Do you anticipate the child meeting the Carrier in the future?
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Do you have any special requirements when choosing a Gestational Carrier? Please explain.
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Do you have any special requests for the Carrier during her pregnancy?
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Please write a short letter to your future surrogate.
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Please assign a primary guardian for your baby, in the event both of you and your spouse die. This information will be used for the surrogacy contract.
Name, Relationship to you, Address, Contact Number
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What is your household Annual Income (combined)?
This information will not be shared with any third party.
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Please fill the full name of your referrer below if applicable.
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I, the undersigned, do hereby swear and affirm that the above statements are true and correct to the best of my knowledge.
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Please upload 3-5 pictures of you and your family.
Upload your pictures...
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Please sign your name
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