Surrogacy Application

-----PLEASE PRINT OR TYPE----

HUSBAND / WIFE

HUSBAND'S NAME: Last _____________________ First ______________________ Middle ________________

WIFE'S NAME: Last _____________________ First ______________________ Middle ________________

ADDRESS: _________________________________ City ______________________ State ____ Zip _________

PHONE: Home (____)________________________ Fax (____)_________________ Cell/Pager (____)________

MARRIAGE : Date __________________________ Place______________________

RESIDENCE: How long have you lived at the above address? _______________________ Do you Own / Rent ?____________

OCCUPATION: Husband _____________________ Business Telephone (___)_________________________________

Employer ___________________________________ Address _______________________________________________

OCCUPATION: Wife _________________________ Business Telephone (___)_________________________________

Employer ___________________________________ Address _______________________________________________

PERSONAL

HUSBAND                                                             WIFE

Place of Birth: ____________________ Age _______ Social Security Number : _______________________ Driver's License Number _______________________ Date of Birth: ___/___/___ Religion _____________ Race _________________ Nationality ___________ Height ________________ Weight _____________ Hair Color _____________ Eye Color ____________ Health Insurance Company _____________________ Have you ever been arrested? __________________ If yes, please explain __________________________ ____________________________________________ Educational Degree ___________________________ Major: ______________________________________ College: _____________________________________ Post-Graduate Education: ______________________

Place of Birth: ____________________ Age _______ Social Security Number : _______________________ Driver's License Number _______________________ Date of Birth: ___/___/___ Religion _____________ Race _________________ Nationality ___________ Height ________________ Weight _____________ Hair Color _____________ Eye Color ____________ Health Insurance Company _____________________ Have you ever been arrested? __________________ If yes, please explain __________________________ ____________________________________________ Educational Degree ___________________________ Major: ______________________________________ College: _____________________________________ Post-Graduate Education: ______________________

If each member of the couple is a different religion, under what religion or belief will the child be raised?_________________

If both members of the couple are employed, will a leave-of-absence be taken or employment terminated in order

to take care of your child? ____ If yes, by whom and for how long?____________________________________________

Does either member of the couple drink? ______ If so, with what frequency?______________________

Does either member of the couple smoke cigarettes? _____ If so, how many per day? _____ How long? ________
 
Have you ever participated in counseling? _______________ If yes, please explain. ___________________________

_____________________________________________________________________________________________________

CHILDREN

HUSBAND Number of Biological Children _________________ Number of Adopted Children _________________ Names & Ages of Children ____________________ ___________________________________________  ____________________________________________ Where do the children reside? __________________ ___________________________________________  ____________________________________________

WIFE Number of Biological Children _________________ Number of Adopted Children _________________ Names & Ages of Children ____________________ ___________________________________________  ____________________________________________ Where do the children reside? __________________ ___________________________________________  ____________________________________________

PRIOR MARRIAGES

HUSBAND Date of Prior Marriage: ________________________ Date and Place of Termination: ___/___/___ _______

WIFE Date of Prior Marriage: ________________________ Date and Place of Termination: ___/___/___ _______

Have you ever filed for divorce, separation or annulment of this marriage? _____ If yes, please explain ____________
___________________________________________________________________________________________________

HOBBIES & INTERESTS

HUSBAND _____________________________________________ _____________________________________________ _____________________________________________

WIFE _____________________________________________ _____________________________________________ _____________________________________________

FINANCIAL STATUS

HUSBAND Annual Income: _______________________________   Amount in Savings: ____________________________   Other Investments: ____________________________ _____________________________________________

WIFE Annual Income: _______________________________   Amount in Savings: ____________________________   Other Investments: ____________________________ _____________________________________________

IN ORDER THAT WE MAY BETTER UNDERSTAND YOUR HISTORY AND ASSIST IN EXPANDING YOUR FAMILY, PLEASE ANSWER THE FOLLOWING QUESTIONS: 

Do you have an infertility diagnosis? ____________________________________________________________________
 
Please briefly explain your history______________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Have you seen a reproductive endocrinologist or other specialist regarding your infertility? ________

Who? ___________________________________ When? _____________________________________
 
____________________________________ _____________________________________

 ___________________________________ _____________________________________


Has a medical doctor confirmed that you are a candidate for surrogacy or the assistance of an egg/sperm donor? _____

Are you considering: Gestational Surrogacy ____ Traditional Surrogacy ____ Egg Donor ____ Sperm Donor _____

Have you already identified a surrogate or donor? ____________

SELECTING YOUR SURROGATE/ DONOR

Are you willing to give identifying information to your surrogate/donor, such as your last name and address? _____________

Would you like to use a particular doctor for the insemination/embryo transfer? _____ Who? _____________________

Do you wish to attend your surrogate's prenatal appointments? ______________________________________________

In the event a multiple pregnancy is achieved, would you consider requesting your surrogate undergo selective reduction?

 ___________________________________________________________________________________________

Would you require your surrogate undergo amniocentesis if it is not required by her treating physician? ____________

In the event laboratory testing indicates fetal abnormalities, would you request the surrogate terminate the pregnancy?

_____________________________________________________________________________________________________

Do you intend to explain to your child how surrogacy or egg/sperm donation assisted you in becoming a parent?

 _________________________________________________________________________________________________________

REFERRAL

How were you referred to our office?______________________________________________________________________
 
PHOTO

Please include a current photograph of yourself.

SIGNATURE

Your signature below indicates that information contained in this Surrogacy Application is true and correct at the time
of completion and will be updated by you should any events occur in your lives which render the information herein
inaccurate prior to finalization of your surrogacy matter.
 

__________________________________________ Commissioning Mother __________________________________________ Commissioning Father

________________  Date ________________  Date