Intended Parent(s) Application

Please answer all questions in a truthful and factual manner to the best of your ability by selecting “YES” or “NO” next to each question. Answer “YES” if the statement is true. Answer “NO” if the statement is not true. All identifying information will be kept confidential and will not be released to potential recipients without your permission.

What is your marital status?

I certify I have a medical need for gestational surrogacy

Do you have any misdemeanor or felony convictions (does not include traffic violations)?

Does your spouse have any misdemeanor or felony convictions (does not include traffic violations)?

Have you ever been denied as intended parent(s) by a physician, fertility center, or other surrogacy agency?

Do you live in a financially stable home to raise a child(ren)?

Source of the Sperm

Source of the Egg

Do You Need Assistance Finding An Egg Donor?

Are you working with a Fertility Clinic? If yes, please indicate the clinic in additional comments.

Do you have embryos created?

Your family. Your choice.

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