Gestational-Carrier-Questionnaire | 09-2022 Name of Gestational Carrier First Middle Last Full legal name for the contract, should match your passport, driver's license, or similar legal document.Date of Birth of Gestational Carrier Month Day Year Gender Male Female Non-Binary Agender Gender Fluid Preferred Pronouns He/Him She/Her They/Them Social Security Number (Gestational Carrier) State of Birth (Gestational Carrier) Maiden Name (Gestational Carrier) Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact Phone (US/Canada)Contact Phone (International)Can you receive text messages? Yes No Email Are you a US Citizen? Yes No If no, please explain and provide residency information.Are you married? Yes No If yes, what is the date of your marriage? MM slash DD slash YYYY If no, are you in a romantic relationship with anyone? Yes No If yes, do they live with you, or do you anticipate they will live with you in the next 12 months? Yes No Will you get married in the next 12 months? Yes No Name of Partner First Middle Last Full legal name for the contract, should match their passport, driver's license, or similar legal document.Gender (Partner) Male Female Non-Binary Agender Gender Fluid Preferred Pronouns (Partner) He/Him She/Her They/Them Date of Birth (Partner) Month Day Year Social Security Number (Partner) State of Birth (Partner) Contact Phone (US/Canada) (Partner)Contact Phone (International) (Partner)Can your partner receive text messages? Yes No Email (Partner) Address (Partner) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is your partner a US Citizen? Yes No If no, please explain and provide residency information.Anticipated Cycle Date Month Day Year Name of Intended Parent First Middle Last Name of Intended Parent First Middle Last Name of Fertility Clinic Fertility Clinic Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Fertility Clinic Phone (US/Canada)Fertility Clinic Phone (International)Fertility Clinic Cycle Coordinator Name First Last Cycle Coordinator Email Cycle Coordinator Phone (US/Canada)Cycle Coordinator Phone (International)Name of Fertility Doctor First Last Surrogacy Agency Surrogacy Agency Email Surrogacy Agency Phone (US/Canada)Surrogacy Agency Phone (International)The following questions will assist in drafting the contract between you and the Intended Parents. Please provide full disclosure in your answers to avoid any confusion.Health InformationDo you have health insurance? Yes No If yes, please explain (i.e., I purchased for the surrogacy journey, through employment, Medicaid, spouse, etc.)Are you on Medicaid? Yes No Are you receiving any State benefits? Yes No food stamps, WIC, or Medicaid for spouse or childrenIf yes, please explain (i.e., I receive Medicaid for my spouse, etc.)Have you confirmed your plan includes maternity coverage? Yes No Have you confirmed there is no surrogacy exclusion? Yes No Have you read your plan document? Yes No Does your plan include maternity coverage? Yes No What are your deductibles and co-pays? Is there a surrogacy exclusion in your plan document? Yes No Health Insurance Company Name Who is responsible for monthly premiums? Who is responsible for all deductibles and co-pays related to the pregnancy? If there are medical expenses beyond that which medical insurance will pay, or if medical insurance is denied, who is responsible? Please list all allergiesCovid-19Have you received a Covid-19 vaccination? Yes No If yes, what is the status of your Covid-19 vaccination? I have received one dose. I have received two doses. I have received two doses and a booster. If no, are you willing to receive Covid-19 vaccination? Yes No I do not agree to get the COVID-19 Vaccine and the Intended Parents respect my decision. I understand if I am terminated by my employer due to not receiving the vaccine, I will not be compensated for lost wages. I also understand, if I test positive for COVID-19 while pregnant, all medical costs associated with the diagnosis will be my responsibility. I understand The Intended Parents and I have agreed to not to get the Covid-19 vaccine during this surrogacy process. The Intended Parents understand if I am terminated by my employer due to not receiving the vaccine, they will compensate me for lost wages. Select only if this statement is true. Previous BirthsPlease list your previous births below. If you've had no previous births enter "N/A" in the required form fields below.Delivery Date Month Day Year Sex Male Female I've had no previous births Birth Weight Number of Weeks Pregnant at Delivery Type of Pain Medication Used Birth Method C-Section Vaginal N/A Delivery Date Month Day Year Sex Male Female Birth Weight Number of Weeks Pregnant at Delivery Type of Pain Medication Used Birth Method C-Section Vaginal Delivery Date Month Day Year Sex Male Female Birth Weight Number of Weeks Pregnant at Delivery Type of Pain Medication Used Birth Method C-Section Vaginal Delivery Date Month Day Year Sex Male Female Birth Weight Number of Weeks Pregnant at Delivery Type of Pain Medication Used Birth Method C-Section Vaginal List all medications you are presently taking and the reasons for eachIf yes, please list the medications, reasons, and time periodsAre you willing to have random drug testing if requested by the Intended Parents? Yes No Who is your preferred OB? First Last At which hospital will you plan to deliver? Maximum number of embryos to transfer How many IVF cycles are you willing to commit to? Termination and ReductionWould you be willing to undergo an amniocentesis or other diagnostic testing to determine the presence of genetic defects? Yes No If there were a serious genetic problem with the fetus and the intended parents wanted to terminate, would you be willing to terminate the pregnancy? Yes No NOTE: Intended Parents will be the decision-makers for any termination or reduction procedure because they created the embryo.Are there any specific conditions in which you would not terminate a pregnancy? Yes No If yes, please explainWould you be willing to reduce a multiple pregnancy (i.e., from twins to a singleton) if there were a medical issue with a fetus and the pregnancy would be compromised if there were not a reduction? Yes No Are you willing to terminate in the following trimesters? 1st trimester, yes. 2nd trimester, yes. 3rd trimester, yes. Are you willing to travel to another state for termination? Yes No General QuestionsAre you willing to carry twins? Yes No Are you willing to carry triplets? Yes No In the case of a pregnancy with multiples (twins or triplets), how do you feel about possibly reducing activity and/or work given that there will likely be bed rest?How much contact would you like with your Intended Parents throughout the pregnancy?Will you provide updates to the Intended Parents between doctor appointments via telephone and/or email/texts? Yes No Will you occasionally send/email pictures of yourself and share details about the pregnancy if the Intended Parents request? Yes No Would you permit the Intended Parents in the delivery room? Yes No If a C-Section delivery is needed, or only one person is allowed in the delivery room, who will you choose? First Last Are you willing to be induced so the Intended Parents could be present for the delivery? Yes No If life and death decisions must be made, who will make the decisions for you? First Middle Last Would you be willing to pump, freeze, and ship your breast milk if your Intended Parents requested it for their child? Yes No Have you ever been a gestational carrier or surrogate mother before? Yes No If yes, please describe your experienceDo you plan to consult with a mental health provider during the course of, or after, the pregnancy? Yes No Have your Intended Parents purchased life insurance for you? Yes No If yes, how much? Do you work outside the home? Yes No Where do you work? What is your position or work title? Do you have Native American Heritage? Yes No If "No" enter "N/A" in any subsequent required fields.If yes, do you have enough heritage to qualify for benefits through the tribe? Yes No What tribe? CommentsName First Middle Last Today's Date Month Day Year Adding your name above will serve as your digital signature verifying that all information you have provided is true to the best of your knowledge.NameThis field is for validation purposes and should be left unchanged. Δ