Intended-Parents-Questionnaire | 09-2022 Name of Intended Parent 1 First Middle Last Full legal name for the contract, and as you'd expect it to appear on the birth certificate for any child. Should match your passport, driver's license, or similar legal documents.Gender of Intended Parent 1 Male Female Non-Binary Agender Gender Fluid Preferred Pronouns of Intended Parent 1 He/Him She/Her They/Them Date of Birth of Intended Parent 1 Month Day Year Birth State of Intended Parent 1 Social Security Number of Intended Parent 1 (U.S. Citizens Only) Email for Intended Parent 1 Contact Phone of Intended Parent 1 (International)Contact Phone of Intended Parent 1 (International)Can Intended Parent 1 receive text messages? Yes No US Citizen? Yes No If no, list citizenships and where you hold passportsAre you married? Yes No If no, are you in a long-term relationship or domestic partnership with someone who is participating in this process with you? Yes No If yes, or if married: Name of Intended Parent 2 First Middle Last Full legal name for the contract, and as you'd expect it to appear on the birth certificate for any child. Should match your passport, driver's license, or similar legal documents.Gender of Intended Parent 2 Male Female Non-Binary Agender Gender Fluid Preferred Pronouns of Intended Parent 2 He/Him She/Her They/Them Date of Birth of Intended Parent 2 Month Day Year Birth State of Intended Parent 2 Social Security Number of Intended Parent 2 (U.S. Citizens Only) Email for Intended Parent 2 Contact Phone of Intended Parent 2 (US/Canada)Contact Phone of Intended Parent 2 (International)Can Intended Parent 2 receive text messages? Yes No Maiden Name of Intended Parent 2 US Citizen? (Intended Parent 2) Yes No If no, list citizenships and where you hold passports. (Intended Parent 2)Date of Marriage Month Day Year 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 Please provide two names and phone numbers for whom we can contact if there is an emergency and they would temporarily care for the child if needed.* First Last Phone (US/Canada)Phone (International)Second Emergency Contact* First Last Phone (US/Canada)Phone (International)Name of Carrier First Middle Last Anticipated Cycle Date Month Day Year 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)Name of Fertility Doctor First Last Name of Cycle Coordinator at Fertility Clinic First Last Cycle Coordinator's Email Cycle Coordinator's Phone (US/Canada)Cycle Coordinator's Phone (International)Surrogacy Agency Surrogacy Agency Email Surrogacy Agency Phone (US/Canada)Surrogacy Agency Phone (International)Escrow Company All Compensated Surrogacies require an Escrow Account.Escrow Company Email Escrow Company Phone (US/Canada)Escrow Company Phone (International)Is this a Compassion Surrogacy? Yes No (No disbursement issued to the Gestational Carrier)The following questions will assist in drafting the contract between you and the Gestational Carrier. Please provide full disclosure in your answers to avoid any confusion.Fertility/Pregnancy HistoryIf not applicable, please enter "N/A" in the subsequent required fields in this section.How long have you been going through infertility (If applicable)? If not applicable, please explainPlease describe your infertility diagnosisMedicalAre you using a donated embryo? Yes No If yes, known or anonymous? Known embryo donor Anonymous embryo donor If known, do you have a copy of your embryo donor agreement or release form? If so, please send to us as soon as possible. Yes No Are you using an egg donor? Yes No If yes, known or anonymous? Known egg donor Anonymous egg donor If known, do you have a copy of your egg donor agreement or release form? If so, please send to us as soon as possible. Yes No Are you using a sperm donor? Yes No If yes, known or anonymous? Known sperm donor Anonymous sperm donor If known, do you have a copy of your sperm donor agreement or release form? If so, please send to us as soon as possible. Yes No Maximum number of embryos you wish to transfer Maximum number of embryos to transfer for a frozen cycle How many IVF cycles are you willing to commit to? How many IVF cycles do you want the Gestational Carrier to commit to? Will genetic testing be done on the embryos? Yes No Gestational Carrier-Specific QuestionsHow much contact would you like with your Gestational Carrier throughout the pregnancy?Do you hope to receive updates from her between doctor appointments via telephone and/or email? Yes No Would you like her to occasionally send/email you pictures of herself and share details about the pregnancy? Yes No Would you like to be in the delivery room when your baby (or babies) is/are born? Yes No If a C-Section is required, would you want to be present? Yes No If yes, would you like to film or take pictures during the delivery? Yes No How would you feel about becoming parents to twins? How would you feel about becoming parents to triplets? If your Gestational Carrier is carrying triplets or more, would you opt to selectively reduce? Yes No What if it is confirmed that the baby has a very serious medical condition, would you choose the option of termination? Yes No (Option would likely be made sometime around 12–16 weeks)If it is determined that the baby has Down's Syndrome, would you choose to terminate the pregnancy? Yes No Do you think you may want your Gestational Carrier to have an amniocentesis? Yes No Is your Gestational Carrier willing to have an amniocentesis? Yes No What hospital do you want the Gestational Carrier to deliver at? Do you have any specific nutritional habits you would like the Gestational Carrier to follow during the pregnancy?Do you want the Gestational Carrier to pump her breast milk? Yes No If yes, how long? Health InsuranceDoes the Gestational Carrier have health insurance currently? Yes No If yes, are you paying the premiums for the policy during the term of your agreement? Yes No If no, please explain.Have you confirmed the policy does not exclude surrogacy? Yes No If no, please explain.Can you confirm that you are responsible for all medical costs not covered by any insurance policy that may be applicable to your Gestational Carrier? Yes No Does the Gestational Carrier have any supplemental health insurance offered through her employer? Yes No If yes, please describeThe contract requires that the Gestational Carrier provides their medical insurance plan for the Intended Parent(s) to review and understand. Please confirm this has occurred. Yes, we have reviewed our Gestational Carrier's insurance plan No, we have not been provided with our Gestational Carrier's insurance plan Does the health insurance plan cover or exclude surrogacy? The plan covers surrogacy The plan does NOT cover surrogacy Who is responsible for all medical expenses if insurance is denied or something is not covered?Covid-19Has your Gestational Carrier received the Covid-19 vaccination? Yes No If no, have you discussed her/your preference? Yes No Do you prefer that your Gestational Carrier be fully vaccinated before transfer? Yes No Gestational Carrier does not agree to get the COVID-19 Vaccine and Intended Parent(s) respect the Gestational Carrier’s decision. The Gestational Carrier understands if she is terminated by her employer due to not receiving the vaccine, she will not be compensated for lost wages. The Gestational Carrier also understands, if she tests positive for COVID while pregnant, all medical costs associated with the diagnosis will be her responsibility. Select only if this statement is true Intended Parent’s and Gestational Carrier have agreed not to get the Covid-19 vaccine during this surrogacy process. Intended Parents understand if Gestational Carrier is terminated by her employer due to not receiving the vaccine, I/We will compensate her for lost wages. Select only if this statement is true FinancialAttached is the agency fee schedule. Please let us know if you have negotiated any changes.Have you purchased life insurance for the Gestational Carrier? Yes No Does the Gestational Carrier work outside the home? Yes No If so, please confirm you are aware of her hourly wage Yes, we are aware of her hourly wage No, we are not aware of her hourly wage Please share any concerns, or discuss any issues that have not been coveredName 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.EmailThis field is for validation purposes and should be left unchanged. Δ