If you are human, leave this field blank. Services Interested In (please select all services required): *
If you select Gestational Surrogacy additional questions will appear.
When will you be ready to start?: 1 Week 1 Month 3 Months 6 Months 1 Year Not Sure
When is the best time to contact you?:
How did you find our website?: Google Search Results Yahoo Search Results Bing Search Results Google Ad Yahoo Ad Other Website Friend Doctor Other
Questions/Comments: Surrogacy questions
Do you have a fertility physician/center that you are working with? If so, please identify:
How many children do you currently have?
How many children do you wish to conceive via surrogacy?
Please tell us a little about yourself. For example, what is your current marital/relationship status and profession / industry of work?
Why have you decided to use a surrogate to build your family? Do you have an infectious disease? This may impact surrogate and IVF Center selection: Have you ever been exposed to and/or infected with Hepatitis B? *
What type of relationship would you like with your surrogate during pregnancy? Close: Regular contact via telephone, email, in-person, video conference, sharing photos Some Contact: Minimal contact via telephone, email, in-person, video conference, sharing photos Anonymous: I am open to some contact, but I do not want my surrogate to know who I am None: No contact at all and I do not want my surrogate to know who I am Does not Matter: Whatever the surrogate mother would prefer Would you like to attend the obstetrical/doctor appointments with your surrogate?
Please note if you are unable to attend appointments but would like someone to be present, please speak with your Client Relations Manager.
Would you like to have sex selection performed on your embryo to determine the sex of your baby? Do you want your surrogate to pump breast milk after the baby is born? Have you ever been arrested for, charged with, or convicted of a felony or misdemeanor in the United States? If yes, please include copies of all arrest records, charging documents, dispositions (outcomes), sentencing records, etc... Have you ever been arrested for, charged with, or convicted of a felony or misdemeanor in any country other than the United States? If yes, please include copies of all arrest records, charging documents, dispositions (outcomes), sentencing records, etc. Do you have any court appearances or alleged criminal offenses outstanding or pending at the time of your application?
If yes, please give details: Have you ever been convicted of a crime against a minor? If yes, please include copies of all arrest records, charging documents, dispositions (outcomes), sentencing records, etc. Signatures
By entering your name below, you acknowledge that you are signing this document electronically and agree that your digital signature will be binding. Your digital signature on this document represents that you agree to the terms of this Website Confidentiality Agreement.
By my signature, I certify that the above information is complete and correct, and I have not omitted to include any information that would make the above information inaccurate or misleading
Digital Signature: *
Digital Signature Partner:
Except for Client’s family members, Client agrees not to disclose to any third party, or use in any manner, information furnished by Conceptual Options, including but not limited to, terms of engagement, costs, fees, processes, time frames, sources, names of other parties, data from any portion of Conceptual Options’ list of donors, surrogates or interviews of persons anticipated or employed to meet Client’s needs. Client will not disclose the confidential information to any person or party without the specific written authorization of Conceptual Options.