Intended Parent Intake Form | The Surrogacy Center

Are you currently working with a fertility clinic?

Yes

No

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

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, how many children?

1

2

3+

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: