Age: Demo
DOB: Demo
Height: Demo
Marital Status: Demo
Location: Demo
Occupation: Demo
Children: Demo
Last Delivery: Demo
# of C-Sections: Demo
Willing to carry twins?: Demo
Experienced Surrogate? Demo
Birth Control? Demo
OB Letter: Demo
Base Compensation: Demo
Covid-19 Vaccine: Demo
Legal Marital Status? Demo
Spouse/Partner: Demo
Do you have any blackout dates when you’d be unavailable? (Vacation/holidays?)?
Demo
Please describe your previous pregnancies:
| Years | Weeks | Gender M/F | Birth Weight | Dates of Employment | Complications |
|---|---|---|---|---|---|
| -- | -- | -- | -- | -- | -- |
How would you describe your overall experience w/ pregnancy?
Demo
Did you breast feed your child(ren), If so for how long?
Demo
Do you want any additional children of your own? (if answer is yes, let them know that surrogacy could possibly affect their fertility in the future)
Demo
What is your current home living situation like? Who lives in your home?
Demo
Does anyone in your household smoke?
Demo
Are you currently taking any medication, if so please explain in detail? i.e. prenatal/vitamins
Demo
Are you currently using any form on contraception? If so, what type and how long? Demo
What is your blood type? Demo
Is your family supportive with your choice of doing a surrogacy journey? Demo
Who would help if you were ordered to be on bed rest for a period of time? Demo
What is your current home living situation like? Who lives in your home? Demo
Does anyone in your household smoke? Demo
Are you willing to transfer untested embryos? Demo
(Embryos that have not undergone Pre-Implantation Genetic Screening- PGS, embryos that have not been genetically tested. In the past befoce technology advanced, PGS had not been done on the embryos and there were plenty of successful cases.)
Are you willing to carry twins? Demo
Are you willing to carry triplets? Demo
In the event that you become pregnant with multiples, would you be okay with a reduction for one or any of the following reasons?
Only if your health was a concern Demo
At the request of the IPs Demo
From 2 to 1: Demo
From 3 to 2: Demo
From 3 to 1: Demo
In the event that the IPs request terminating the pregnancy, would you agree to one or any of the following:
Due to quality of life reasons only i.e. Genetic disorder, heart defect, short life expectancy
Demo
Only if your health was a concern Demo
At the request of the IPs Demo
Would there be any reason you would not be willing to terminate? Or for a specific reason? (i.e. cleft lip, missing limb, gender)
Demo
Are you willing to transfer untested embryos? Demo
(Embryos that have not undergone Pre-Implantation Genetic Screening- PGS, embryos that have not been genetically tested. In the past before technology advanced, PGS had not been done on the embryos and there were plenty of successful cases.)
Are you willing to work with intended parents that may be HIV positive?
Demo
Please describe your occupation/job title
Demo
Are you full time or part time? Demo
What are your usual work hours? Demo
Are they flexible with you taking time off for appointments?
Demo
Do you feel you can dedicate your time and commit yourself to the surrogacy process, given your current schedule and responsibilities?
Demo
Do you have reliable transportation? Demo
Do you have a valid driver’s license? Demo
How do you see your ideal surrogacy journey? Demo
What kind of contact would you like to have after the delivery? Demo
What do you like to do in your spare time? Demo
What is something you’ve always wanted to do? (Sky diving, travel, etc.) Demo
What is your favorite food? Demo
Do you have any special dietary needs? Demo
Use three words that best describe your personality Demo
What is your favorite part about being a mom? Demo
What kind of goals do you have set for yourself within the next five years? Demo