Contact and Personal Information:
*
First Name
Last Name
Phone number
*
(###)
###
####
Email
*
Facebook name (if you use it)
Preferred way to be reached
*
Phone
Text
Email
Facebook
WhatsApp
Pronouns
She / Her
He / Him
They / Them
She / They
He / They
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Citizenship status:
*
Emergency Contact Info
*
First Name
Last Name
Phone Number
(###)
###
####
Date of Birth:
*
MM
DD
YYYY
Which languages do you speak?
What is your primary method of transportation?
*
Own your car
Public transit
Uber / cab
Ride share
What is your current relationship status
*
Married
In a relationship - common-law
In a relationship - not cohabitating
Single
Divorced
Widowed
Polyamorous
Partners Contact Info (if applicable)
First Name
Last Name
Partners Work
P/T Employment
F/T Employment
Evenings
Weekends
Currently Unemployed
Have you or your partner been involved in legal proceedings or have pending claims?
*
Have you or your partner ever been charged with or convicted of a crime?
*
Does your partner support your decision to be a surrogate? (If applicable)
Height:
*
Weight:
*
Do you have a regular menstrual cycle?
*
If no, please explain
Are you currently breastfeeding?
*
If yes, please share when you're planning on stopping (no pressure of when, it can just affect your timeline)
Are you currently using birth control?
*
If yes, what birth control are you taking?
Approximate date of your last OB appointment and results:
*
Approximate date of your last Pap test and results:
*
Do you currently have a family doctor?
*
If yes, please provide their full name and number:
First Name
Last Name
Phone
(###)
###
####
Do you smoke cigarettes or vape?
*
Do you use cannabis products?
*
If yes, how often? Are you willing to stop for the surrogacy journey?
Have you ever been diagnosed with a sexually transmitted infection (STI)?
*
If yes, please specify and when you were treated.
Have you ever had an abortion?
*
If yes, can you please provide how far along you were and approx. date?
Are you currently taking any medications?
*
If yes, please list the medication name, dosage and why they were prescribed:
Have you taken any other medications in the past year?
*
If yes, please list:
Have you had any surgeries or hospital stays (including cosmetic)?
*
If yes, please describe and provide date:
Have you been diagnosed with or treated for a mental health condition or hospitalised? (e.g. depression, anxiety, PTSD, bipolar disorder)?
*
If yes, please share your current status and treatment details (medication, therapy, etc.):
If you're currently taking medication and the fertility Doctor needs you to switch to a pregnancy safe medication are you ok with changing your medication to a pregnancy safe option?
Are you comfortable with your intended parents making decisions around termination if medically recommended by the physician or if aligned with their beliefs?
*
If no, please describe your termination views:
How many pregnancies have you had?
*
How many live births have you had? (You will need to provide requested birth info at a later date)
*
What year(s) were your births?
*
Have you experienced a pregnancy loss?
*
If yes, how many weeks gestation were you?
If you're an experienced surrogate, can you share how many previous IVF transfers you have had. (positive and failed transfers)
Do you currently pay for childcare or after-school care?
What hours are your children in care?
What do you currently pay for childcare per week ?
If you were on bed rest, what kind of additional childcare support would you need? Would you need to hire help?
Estimated weekly cost for extra childcare (beyond what you currently pay):
If on bed rest, what weekly amount would you need for housekeeping?
What's your current job?
Employer’s name:
Does your job require lifting over 30 lbs?
Does your job involve exposure to chemicals or other risks during the pregnancy?
If yes, please explain:
How many hours per week do you work?
Are you paid hourly or salary? Please provide either hourly wage or gross annual salary.
Approximately how much do you receive on each paycheque (after tax)?
Approximate weekly income (NET):
Will you be eligible for Employment Insurance (EI) if needed for bed rest or post-birth?
*
Yes
No
Unsure
Do you have any other income sources?
*
If yes, please describe and include weekly amount
What is your expected reimbursement amount during this process??
*
What are you hoping for with this experience?
Are there specific values or preferences you’d like us to consider when matching you with intendedhopeful parents?
(e.g. LGBTQ+ families, open communication, cultural beliefs)
What kind of relationship would you like to have during your pregnancy? What about after delivery?
Tell us a little about yourself, your family, and anything you’d love for us—or your future hopeful parents to know.
