INTENDED PARENT QUESTIONNAIRE

Thank you for your cooperation with completing this form. This form will be used to help select your surrogate mother and will be shown to potential surrogates to ensure an appropriate match. Please be as descriptive and open as possible.

This form in NO way commits you to our full agency fees.

1. Intended Parent 1 Name (required):

Age:


Intended Parent 2 Name:

Age:


2. Client Relations Name (required):


3. Do you have a fertility physician/center that you are working with? If so, please identify:



4. How would you like to be contacted? Please provide specifics so that your privacy can be maintained.

Telephone Number:

May we leave a voice mail at the above number?: YesNo

Email (required):

Fax:

Mail:


5. How did you hear about Conceptual Options?



6. How many children do you currently have?


7. How many children do you wish to conceive via surrogacy?


8. Please tell us a little about yourself. For example, what is your current marital/relationship status and profession / industry of work?



9. Why have you decided to use a surrogate to build your family?



10. Do you have an infectious disease? This may impact surrogate and IVF Center selection.

YesNoUnsure

11. What type of relationship would you like with your surrogate during pregnancy?


12. Would you like to attend the obstetrical/doctor appointments with your surrogate?

*YesNo

Please note if you are unable to attend appointments but would like someone to be present, please speak with your Client Relations Manager.


13. Would you like to have sex selection performed on your embryo to determine the sex of your baby?

YesNo

14. Do you want your surrogate to pump breast milk after the baby is born?

YesNoUndecided

15. 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.

YesNo


16. 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.

YesNo


17. Do you have any court appearances or alleged criminal offenses outstanding or pending at the time of your application?

YesNo

If yes, please give details:


18. 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.

YesNo

19. 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

     
Intended Parent 1                                                                                       Date
     
Intended Parent 2                                                                                       Date