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IP#1
Name
Sex
—Please Select—
Male
Female
Date of Birth
Occupation
IP#2
Name
Sex
—Please Select—
Male
Female
Date of Birth
Occupation
Address
City
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China, People's Republic of
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French South Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Island
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Johnston Island
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion Island
Romania
Russia
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre & Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and South Sandwich
Spain
Sri Lanka
Stateless Persons
Sudan
Sudan, South
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan, Republic of China
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America (USA)
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna Islands
Western Sahara
Yemen
Zambia
Zimbabwe
Clinic Information
Name of the clinic
Physician
Do you have embryos?
Yes
No
PGS?
Yes
No
Intended parent #1
Name
Where were you born?
Where did you grow up?
Do you have brothers and sisters? How many?
Are your parents alive?
Yes
No
Did you go to college? Where?
What do you like to do in your spare time?
What is your favorite?
Book
Music
Food
Vacation
Holiday
Time of the year
How will your friends & family describe you?
Intended parent #2
Name
Where were you born?
Where did you grow up?
Do you have brothers and sisters? How many?
Are your parents alive?
Yes
No
Did you go to college? Where?
What do you like to do in your spare time?
What is your favorite?
Book
Music
Food
Vacation
Holiday
Time of the year
How will your friends & family describe you?
Questions for both Intended Parents
How did you meet?
How long have you been together?
Married? If yes, for how long?
Do you have any children?
If so, what are their names and ages?
Do you have a faith or a religious affiliation? If yes, what?
What are your reasons for choosing gestational surrogacy?
Do you want a singleton or twins?
Using an egg donor?
Do you want to be present for the transfer?
Do you want to be in the room during the birth?
Are you interested in having your surrogate pump breast milk? For how long?
If the surrogate’s physician recommended an amniocentesis, how would you feel about this?
What is your view regarding abortion or selective reduction in the event of the baby having birth defects, Down syndrome or the pregnancy not being viable?
Would you choose to selective reduce with triplets or more?
Would you be interested in Zoom call for the appointments you are unable to attend?
What kind of relationship would you like to have with your surrogate during the pregnancy?
After the baby is born, do you plan on staying in contact with your surrogate?
What will you tell your child about your surrogate?
Do you think you will want to have a sibling for your child?
If the transfer is unsuccessful, will you want to try again? If yes, how soon after?
Please use this space to pass along a message to your potential surrogate
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