Form

Please help us get to know you and learn what type of carrier you're looking for by answering the questions below.
# of IPs:*
Family Photo:
P1 Name:*
P2 Name:
P1 DOB:*
Month Day Year
P2 DOB:
Month Day Year
P1 Gender:*

Male Female
P2 Gender:

Male Female
Address:*
Phone:*
P1 Cell Phone:
P2 Cell Phone:
Who is completing this form?

P1 P2
Who will be our primary contact person?

P1 P2
P1 Email:*
P2 Email:
Should we cc email correspondence to both IPs?

Yes No
Fertility Story:*
Family Type:*

Married Common Law Marriage Living Together Unmarried Straight Gay Lesbian Single Male Single Female Adopted Children in Home Biological Children in Home Children via Egg Donation in Home Children via Surrogacy in Home Foster Children in Home
Approximate Start Date:
- Month - Day Year
at
/ Hour Minutes
Helpers Needed:*

Gestational Surrogate Traditional Surrogate Ovum Donor Sperm Donor Undetermined
Have you been working with a fertility clinic?

Yes No
Clinic Name and Location:
Is this the clinic you plan to have oversee this process?

Yes No Unsure
Have you spoken with a fertility counselor or psychologist about the emotional side of assisted reproduction?

Yes No
Will IF (or family member) be providing sperm?

Yes No Unsure
Has this sperm been evaluated by fertility clinic?

Yes No
Has sperm been deposited for cleaning/quarantine?

Yes No Unsure
Will IM (or family member) be providing ovum?

Yes No Unsure
Has this ovum source been evaluated by the clinic?

Yes No
Are frozen ovum or embryos available?

Yes No
Do you intend to use these ovum/embryos?

Yes, before attempting a fresh cycle Yes, IM will attempt pregnancy simultaneously. No, these will be used only as last resort.
Please decribe your ideal surrogate:
Do you require an experienced SM?

Yes No Not using SM
What do you feel is fair compensation for a SM who meets your requirements?
Are any of the IPs members or veterans of the US armed forces?

Yes Yes, but retired No
Do any of the IPs work as a police officer, firefighter, or emergency services worker?

Yes Yes, but retired No
Do any of the IPs work as a K-12 school teacher or Registered Nurse?

Yes Yes, but retired No
Where should your fertility helpers live?

In my home state In a neighboring state On the east coast On the west coast In the south Anywhere with favorable laws for my situation
What are your feelings about the possibility of multiples and selective reduction?
What are your feelings about termination for abnormalties?
What type of relationship would you like to have with your SM during pregnancy?
What type of relationship would you like to have with your SM after delivery?
What are your time expectations regarding this process from start to finish?
Use this space to tell RM staff anything else you feel we should know:
What are your primary concerns regarding assisted reproduction?
What questions do you have that our Program Director should address in your consultation/proposal?
Should be Empty: