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Intended Parent Intake Form

1Intended Parent 1
2Intended Parent 2
3Additional Questions

First Name

Last Name

Phone Number

Email

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Today Clear

Country

City

State

Marital Status

Wedding Date

Sun Mon Tue Wed Thu Fri Sat

Today Clear

Orientation

Do you have a medical indication for pursuing surrogacy? Please explain.

Are you going through this journey with a spouse/partner?

First Name

Last Name

Phone Number

Email (different email address from first Intended Parent required)

Please ensure the second IP has a unique email address. Using the same email address for both IPs will prevent the second IP from being able to log into their User Portal, which will also prevent them from signing any legal documents.

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Today Clear

Are you currently working with a fertility clinic?

Please tell us where you are in the process of selecting a fertility clinic:

Just starting to gather information about fertility clinics

Have selected a clinic but do not have an appointment

Gathering information about agencies before selecting a fertility clinic

Other

Please explain:

Please provide the name of the clinic and doctor.

Please provide the date of your last scheduled or your next upcoming visit with your reproductive endocrinologist.

Sun Mon Tue Wed Thu Fri Sat

Today Clear

Do you have embryos created?

Yes

No

How many embryos?

Are your embryos genetically tested?

If your current embryos do not result in a pregnancy, do you have a plan to create more embryos? Please provide a brief explanation.

Do you have children?

Yes

No

If so, what are their names/ages? Tell us a little about them, gender, hobbies, etc.

Do you have the financial means to proceed immediately?

Yes

No

Unsure

Are you applying to other surrogacy agencies?

Yes

No

How did you hear about us?

Google

Clinic Referral

Social media

Personal referral

Other

If this is a personal referral, please share name individual's name:

If other, please specify:

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