Test 1Choose Your Form:2Tell Us About You3Pregnancy4Medical5Decision6Employment7Personality8Tell Us About You9Pregnancy10Medical11Surrogacy12Decision13Enployment14Personality Choose Your Form:(Required) First Time Surrogate Returning Surrogate Full Name:(Required) Age:(Required) DOB:(Required) Height(Required) Marital Status:(Required) Location:(Required) Occupation:(Required) Children:(Required) Last Delivery:(Required) # of C-Sections:(Required) Willing to carry twins?(Required) Experienced Surrogate?(Required) Birth Control?(Required) OB Letter:(Required) Base Compensation:(Required) Covid-19 Vaccine:(Required) Legal Marital Status?(Required) Spouse/Partner:(Required) Do you have any blackout dates when you’d be unavailable? (Vacation/holidays?)?(Required) Please describe your previous pregnancies:Pregnancy table Year Weeks Gender M/F Birth Weight Dates of Employment Complications Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. How would you describe your overall experience w/ pregnancy?(Required) Did you breast feed your child(ren), If so for how long?(Required) 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)(Required) Are you currently taking any medication, if so please explain in detail? i.e. prenatal/vitamins(Required) Are you currently using any form on contraception? If so, what type and how long?(Required) What is your blood type?(Required) Is your family supportive with your choice of doing a surrogacy journey?(Required) Who would help if you were ordered to be on bed rest for a period of time?(Required) What is your current home living situation like? Who lives in your home?(Required) Does anyone in your household smoke?(Required) Are you willing to transfer untested embroys?(Required) (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?(Required) Are you willing to carry triplets?(Required) 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(Required) At the request of the IPs(Required) From 2 to 1:(Required) From 3 to 2:(Required) From 3 to 1:(Required) 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(Required) i.e. Genetic disorder, heart defect, short life expectancyOnly if your health was a concern(Required) At the request of the IP(Required) Would there be any reason you would not be willing to terminate? Or for a specific reason? (i.e. cleft lip, missing limb, gender)(Required) Are you willing to transfer untested embryos?(Required) 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?(Required) Please describe your occupation/job title(Required)Are you full time or part time?(Required) What are your usual work hours?(Required) Are they flexible with you taking time off for appointments? Do you feel you can dedicate your time and commit yourself to the surrogacy process, given your current schedule and responsibilities?(Required) Do you have reliable transportation?(Required) Do you have a valid driver’s license?(Required) How do you see your ideal surrogacy journey?(Required)What kind of contact would you like to have after the delivery?(Required) What do you like to do in your spare time?(Required) What is something you’ve always wanted to do? (Sky diving, travel, etc.)(Required) What is your favorite food?(Required) Do you have any special dietary needs?(Required) Use three words that best describe your personality(Required) What is your favorite part about being a mom?(Required) What kind of goals do you have set for yourself within the next five years?(Required) Please upload 5-10 photos Drop files here or Select files Max. file size: 2 GB, Max. files: 10. Professional Portrait Baby PIctures Family Pictures Hobbies(Camping, swimming, traveling, etc) Full Body Photos Photos of Graduations Full Name:(Required) Age:(Required) DOB:(Required) Height:(Required) Marital Status:(Required) Location:(Required) Occupation:(Required) Children:(Required) Last Delivery:(Required) # of C-Sections:(Required) Willing to carry twins?(Required) Experienced Surrogate?(Required) Birth Control?(Required) OB Letter:(Required) Base Compensation:(Required) Covid-19 Vaccine:(Required) Legal Marital Status?(Required) Spouse/Partner:(Required) Do you have any blackout dates when you’d be unavailable? (Vacation/holidays?)?(Required) Please describe your previous pregnancies:Surrogate Pregnancy Year Weeks Gender M/F Birth Weight Dates of Employment Complications Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. How would you describe your overall experience w/ pregnancy?(Required) Did you breast feed your child(ren), If so for how long?(Required) 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)(Required) What is your current home living situation like? Who lives in your home?(Required) Does anyone in your household smoke?(Required) Are you currently taking any medication, if so please explain in detail? i.e. prenatal/vitamins(Required) Are you currently using any form on contraception? If so, what type and how long?(Required) What is your blood type?(Required) Please describe your previous surrogate pregnancies:Surrogency Year Weeks Gender M/F Birth Weight Dates of Employment Complications Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Would you say that your Surrogate pregnancy(ies) were any different than your own pregnancies?(Required) Did you provide breast milk to your intended parents? If so, for how long?(Required) How was your relationship with the intended parent family during your previous Surrogacy journey(s)?(Required) Is your family supportive with your choice of doing another journey?(Required) What made you want to do another journey?(Required) What was your favorite part about being a surrogate?(Required) Is there anything in particular you wouldn’t be ok with in your new journey?(Required) Who would help if you were ordered to be on bed rest for a period of time?(Required) Are you willing to transfer untested embroys?(Required) (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?(Required) Are you willing to carry triplets?(Required) 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(Required) At the request of the IPs(Required) From 2 to 1:(Required) From 3 to 2:(Required) From 3 to 1:(Required) 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(Required) i.e. Genetic disorder, heart defect, short life expectancyOnly if your health was a concern(Required) At the request of the IP(Required) Would there be any reason you would not be willing to terminate? Or for a specific reason? (i.e. cleft lip, missing limb, gender)(Required) Are you willing to transfer untested embryos?(Required) 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?(Required) Please describe your occupation/job title(Required)Are you full time or part time?(Required) What are your usual work hours?(Required) Are they flexible with you taking time off for appointments?(Required) Do you feel you can dedicate your time and commit yourself to the surrogacy process, given your current schedule and responsibilities?(Required) Do you have reliable transportation?(Required) Do you have a valid driver’s license?(Required) How do you see your ideal surrogacy journey?(Required)What kind of contact would you like to have after the delivery?(Required) What do you like to do in your spare time?(Required) What is something you’ve always wanted to do? (Sky diving, travel, etc.)(Required) What is your favorite food?(Required) Do you have any special dietary needs?(Required) Use three words that best describe your personality(Required) What is your favorite part about being a mom? What kind of goals do you have set for yourself within the next five years?(Required) Please upload 5-10 photos Drop files here or Select files Max. file size: 2 GB, Max. files: 10. Professional Portrait Baby PIctures Family Pictures Hobbies(Camping, swimming, traveling, etc) Full Body Photos Photos of Graduations Δ
