IP Application

1Instruction
2Personal Information
3IP 2
4Medical/Background History
5Donor Details
6How did you hear about us?

Please answer all questions in a truthful and factual manner to the best of your ability by selecting "TRUE" or "FALSE" next to each question. Answer "TRUE" if the statement is true. Answer "FALSE" if the statement is not true. All identifying information will be kept confidential and will not be released to potential recipients without your permission.

First Name

Middle Name

Last Name

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Phone Number

Street Address

Street Address 2

City

Country

State

Zip Code

I/We are married, single, divorced, or widowed, but are not separated from a partner.

I/We have a valid drivers license, reliable transportation, and car insurance.

I/We are not recipients of any state or federal financial assistance (welfare, housing assistance, food stamps, WIC, etc).

I/We are financially stable.

Do you have children currently?

Do you have a spouse or partner?

Yes

Marital Status:

I/We have a medical need for gestational surrogacy

I/We have never been denied as intended parent(s) by a physician, fertility center, or other surrogacy agency.

I/We live in a stable household where nobody smokes, uses drugs, or abuses alcohol.

I/We have not been in a substance abuse program.

I/We have no misdemeanor or felony convictions (does not include traffic violations).

I/We are physically capable of caring for any child(ren).

I/We have no history of psychiatric disorders (ex. schizophrenia, psychotic disorder, manic episodes, hallucinations, suicidal ideations, etc).

Source of the Sperm?

Source of the Egg?

Do You Need Assistance Finding An Egg Donor?

Are You Working with a Fertility Clinic?

Do You Have Embryos Created Already?

How many embryo attempts would you be comfortable with?

How many embryos do you plan to transfer at one time?

If A Resulting Child Has A Genetic Or Physical Abnormality That Is Discovered During The Pregnancy, Would You Choose To Terminate The Pregnancy?

Are you willing to terminate the pregnancy if the resulting child is diagnosed with Down Syndrome?

Would you consider selective reduction in cases of multiples (2, 3, or more). Please specify.

In the event you are unavailable/incapacitated, please list the name of a guardian for your child.

Are you willing to work with a Gestational Carrier that has not received the Covid vaccination?

Would You Be Comfortable Working With The Gestational Carrier That Has Received or Plans On Receiving The Covid Vaccine In The Future?

Before Pregnancy

During Pregnancy

Before and During Pregnancy

Only If Physician Recommends It

Not At Any Time

Other - Explain Below

How did you find out about The Stork's Nest?

Additional Comments