Intended Parent Intake Form
Thank you for taking the time to complete the Intended Parent Intake Form. Gestational Surrogacy is a very personal journey, and this Intake Form will help Paying It Forward Surrogacy, LLC (PIFS) learn about you, your reasons for seeking a gestational surrogate, your IVF clinic and the name and contact information for your reproductive endocrinologist.This is also your opportunity to provide PIFS with the criteria that are important for you in selecting a potential surrogate (including where the surrogate lives, views on termination for medical necessity, desire for a single vs. double embryo transfer, and the type of relationship you would like to maintain during and after your journey).
Intended Parent 1
Full Name
*
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Religion
Primary Language spoken in home
Do you have children?
Do you or your partner smoke or frequently around secondhand hand smoking?
How long have you been married?
Would you consider yourself "no termination", unless gestational carrier life was at risk?
Marital status
Occupation
Phone Number
*
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Profession
What is your current work schedule like?
Intended Parent 2
Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Religion
Occupation
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Profession
If you are married or partnered, please share with us about your relationship.
What is your home like? How long have you lived there?
What is your current work schedule like?
If you have children, please tell us about them
Do you have any favorite family traditions?
Have you shared your surrogacy plans with family and friends?
What would you describe as you and your partners personalities?
Do you or your partner drink alcohol. If yes, how often?
How do you and your partner/spouse handle disagreements?
What would you like to change about yourself and why?
Please share how you think your life has turned out so far?
Think about your best friend and list a few things about your friend that explain why you get along so well?
Hobbies or favorite activites?
Any or short or long term goals?
Where do you see you and your family in ten years?
Why are you looking into gestational surrogacy now?
What do you anticipate this journey to look like?
Do you have any concerns about this process?
Have you gone through a surrogate journey before? If so, please share with us how it went
What is your ideal match for a gestational carrier?
How involved do you expect to be involved in the pregnancy
How much contact do you expect with the gestational carrier?
What kind of relationship do you expect with the gestational carrier once the baby arrives?
Do you and/or your partner/spouse want to be present during the birth?
What delivery settings are you comfortable with?
How many attempts are you willing to undergo to have a baby?
How many embryos are you looking to transfer at one time (1 or 2)?
What are your thoughts on twin/triplet, etc pregnancies?
Under what circumstances would you consider terminating the pregnancy?
Whose decision should it be to terminate or selectively reduce a pregnancy
Are you using any type of gamete donor (Egg, sperm, ebmbryo?)
Have you experienced pregnancy loss?
Any pertinent fertility history?
Do you have any frozen embryos? If so, how many
Medical Information
Briefly describe the reason for seeking a gestational surrogate:
IVF Clinic/Doctor (Name and Address):
Have you already created embryos?
How many embryos do you have and are they genetically tested?
Check if any of the following used:
Egg donor
Sperm donor
Embryo donation
Would you wish to terminate a pregnancy for genetic issues or major health issues?
Yes
No
Would you selectively reduce a pregnancy for multiples greater then twins?
Yes
No
Would you ideally like to transfer one or two embryos?
Your Surrogate
Please describe the relationship you would like with your surrogate including the frequency of communication:
Ideal location of surrogate;
Are you willing to pay for surrogate-friendly health insurance?
Yes
No
Would you like the birth to take place at a hospital?
Yes
No
Submit
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