Your Name *

First Name

Last Name

Partner's Name *

First Name

Last Name

Marital status

Married

Not married

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Partner's Phone *

(###)

###

####

Do you currently have children? *

Yes

Not yet

Will your embryos be genetically tested? *

Yes

No

Haven't decided yet

Additional Geography and Legal Considerations *

Surrogacy laws vary state-to-state. Many states have a pre-birth order process, which allows the names of both intended parents to go directly on the birth certificate. In other states, the carrier's name as well as the intended father’s are listed on the birth certificate. In this situation, the intended parents' will complete a step-parent adoption, removing the surrogates’ name from the birth certificate.

My preference is to work within states that provide pre-birth orders only

No preference

I would like more information

Special consideration: *

New York State is the only state that requires intended parents to pay for the surrogate’s insurance premiums for one year post-birth.

I am willing to consider a NY state surrogate

I am not willing to consider a NY state surrogate

COVID Vaccination *

The American Academy of Obstetricians and Gynecologists recommends that all pregnant women and those seeking to become pregnant be vaccinated against COVID due to the associated complications with the virus on pregnancy. Please confirm if you only want to work with a carrier who has been vaccinated.

Vaccinated carriers only

Non-vaccinated carriers are acceptable

Dietary Considerations *

The type of food a carrier consumes can become an issue if her diet does not resemble the food choices that the intended parents would make if they were carrying the pregnancy. When foods such as non-GMO dairy and organic produce are preferred, some IPs will often to provide funds to cover the additional costs related to these food items.

I would be willing to cover the costs of my preferred dietary considerations.

I am fine with whatever dietary preferences my carrier may have.

Single Embryo Transfer: *

To ensure the best outcome and health of the carrier and the pregnancy, a single embryo transfer (SET) is recommended. If embryo quality is concerning, a Double Embryo Transfer (DET) might be recommended. This is becoming increasingly rare and must be agreed upon in advance of matching with the surrogate.

I understand

I would like more information

Selective Reduction: *

Should a single embryo or double embryo split resulting in two or three fetuses, please give thought to whether or not you would want to reduce the pregnancy to a single fetus or twins. This would have to be agreed upon before matching.

Would want to reduce pregnancy to one

Would want to reduce pregnancy to two

Would not want to reduce pregnancy

Termination: *

Like selective reduction, termination is a critical element which should be mutually agreed upon before matching. Because a carrier cannot be forced to terminate, this is an area that requires extensive discussion, including being very clear about in which situations termination would or would not be considered. It is also essential that both parties share the same understanding of topics such as non-compatible with life and the range of severity for conditions for Down Syndrome. This aspect of a surrogacy journey underscores the need for the best possible match. We will discuss this in-depth during our meeting.

I understand