Intake Form | Surrogacy Miracles & Consulting LLC

Date form completed

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First Name

Last Name

Email

Phone Number

Address

Address Line 2

City

State

Zip Code

Current Age

Date of Birth (Month/Day/Year)

Current IVF Clinic Name and Location

Please share what has brought you to surrogacy.

Have you ever been pregnant? If so what was the result of pregnancy?

Do you currently have Embryos? How many? Are they tested?

Any history of sexually transmitted diseases for you and/or your partner?

Are you financially comfortable to support surrogacy cost? (select all that apply)

Yes

No

I would like information on Grants and Loans

Are you able to commit to the process time and responsibility of being an Intended Parent?

Yes

No

Unsure at this time

How did you learn of Surrogacy Miracles & Consulting?