Step 1 of 5 20% Intended Parent #1 Intended Parent #1Name* First Last Gender* Date of birth:* MM slash DD slash YYYY Phone*Email* WeChat/WhatsApp ID: Intended Parent #2 Intended Parent #2Is there a second parent? Yes No Name First Last Gender Date of birth: MM slash DD slash YYYY PhoneEmail WeChat/WhatsApp ID: About your family/relationship: About your family/relationship:Sexual Orientation* Marital Status* Married Engaged Relationship (cohabitating) Relationship (living separately) Single Divorced Legally Separated Where do you live? Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Do you have other children? (if yes, please give details)*What characteristics are you looking for in a surrogate mother?*What type of contact would you like to have with the surrogate mother throughout the process?* Fertility clinic information: Fertility clinic information:What fertility clinic and doctor are you working with?* Do you already have embryos created? If so, how many?* Are your embryos PGS tested?* If you run out of embryos, will you be making more embryos?* Do you want your surrogate mother to carry twins?* Do you have any medical issues or conditions we should be aware of (Hepatitis B+, HIV+, etc?)* Was the egg source (Intended mother or Egg donor) or sperm source (Intended Father or sperm donor) treated for any infections in the 6 months preceding the IVF cycle?* Please tell your surrogate mother a little bit about yourself: Please tell your surrogate mother a little bit about yourself:What is your occupation? Please be specific.*Do you have any hobbies or special interests?*Please attach some photos of you and your partner (if applicable)Maximum file size: 32MB Drop files here or Select files Accepted file types: jpg, gif, png, pdf, hief, jpeg, Max. file size: 32 MB. EmailThis field is for validation purposes and should be left unchanged. Need help or have questions about the application? Get in touch with us and we'll help you through the process.
