Intended Parent Profile „*“ zeigt erforderliche Felder an Schritt 1 von 5 20% Name* Vorname Nachname Email Primary Phone*Alternate Phone*Marital Status* Married Single Committed Relationship (Living Together) Committed Relationship (Living Together) How long have you been in a committed relationship?*Will your partner be pursuing surrogacy with you?* Yes No Partner's Name* Vorname Nachname Partner's Email* Partner's Primary Phone*Partner's Alternate Phone*Address* Anschrift Anschrift Zusatz Stadt Bundesstaat / Provinz / Region PLZ Land AfghanistanAlbanienAlgerienAmerikanisch-SamoaAmerikanische JungferninselnAndorraAngolaAnguillaAntarktisAntigua und BarbudaArgentinienArmenienArubaAserbaidschanAustralienBahamasBahrainBangladeshBarbadosBelgienBelizeBeninBermudaBhutanBolivienBosnien und HerzegowinaBotswanaBouvetinselBrasilienBritische JungferninselnBritisches Territorium im Indischen OzeanBrunei DarussalamBulgarienBurkina FasoBurundiCaymen InselnChileChinaCookinselnCosta RicaCuraçaoCôte d'IvoireDemokratische Volksrepublik LaosDeutschlandDjiboutiDominicaDominikanische RepublikDänemarkEcuadorEl SalvadorEritreaEstlandEswatiniFalklandinselnFidschiFinnlandFrankreichFranzösisch-GuayanaFranzösisch-PolynesienFranzösische Süd- und AntarktisgebieteFutuna (Wallis und Futuna)Färöer-InselnGabunGambiaGeorgiaGhanaGibraltarGrenadaGriechenlandGroßbritannienGrönlandGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard und McDonaldinselnHeiliger StuhlHondurasHongkongIndienIndonesienIrakIranIrlandIslandIsle of ManIsraelItalienJamaikaJapanJemenJerseyJordanienKambodschaKamerunKanadaKap VerdeKaribische NiederlandeKasachstanKatarKeniaKirgistanKiribatiKokosinselnKolumbienKomorenKongoKongo, Demokratische Republik desKorea. Demokratische VolksrepublikKroatienKubaKuwaitLesothoLettlandLibanonLiberiaLibyenLiechtensteinLitauenLuxemburgMacauMadagaskarMalawiMalaysiaMaledivenMaliMaltaMarokkoMarshall-InselnMartiniqueMauretanienMauritiusMayotteMexikoMikronesienMoldawienMonacoMongoleiMontenegroMontserratMosambikMyanmarNamibiaNauruNepalNeukaledonienNeuseelandNicaraguaNiederlandeNigerNigeriaNiueNordmazedonienNorfolkinselNorwegenNördliche MarianenOmanOsttimorPakistanPalauPalästina, BundesstaatPanamaPapua Neu GuineaParaguayPeruPhilippinenPitcairninselnPolenPortugalPuerto RicoRuandaRumänienRussische FöderationRéunionSaint-BarthélemySaint-Pierre und MiquelonSalomonenSambiaSamoaSan MarinoSaudi-ArabienSchwedenSchweizSenegalSerbienSeychellenSierra LeoneSimbabweSingapurSint MaartenSlovenienSlowakeiSomaliaSpanienSri LankaSt. Helena, Ascension und Tristan da CunhaSt. Kitts und NevisSt. LuciaSt. MartinSt. Vincent und die GrenadinenSudanSurinamSvalbard und Jan MayenSyrien, Arabische RepublikSão Tomé und PríncipeSüdafrikaSüdgeorgien und die Südlichen SandwichinselnSüdkoreaSüdsudanTadschikistanTaiwanTansania, Vereinte RepublikThailandTogoTokelauTongaTrinidad und TobagoTschadTschechienTunesienTurkmenistanTurks- und CaicosinselnTuvaluTürkeiUS Minor Outlying IslandsUgandaUkraineUngarnUruguayUsbekistanVanuatuVenezuelaVereinigte Arabische EmirateVereinigte Staaten von AmerikaVietnamWeihnachtsinselWeißrusslandWestsaharaZentralafrikanische RepublikZypernÄgyptenÄquatorial GuineaÄthopienÅlandinselnÖsterreich Name and location of your fertility center* Intended Parent 1 InformationPlace of birth*Dieses Feld wird bei der Anzeige des Formulars ausgeblendetLanguages spokenLangugages Spoken English Chinese Spanish German French Italian Portuguese Other Race & Ethnicity*Date of Birth* MM Schrägstrich TT Schrägstrich JJJJ Age*Gender* Male Female Non-binary Name of Emergency Contact (Other than spouse)*Emergency Contact Phone*Current occupation*Current Employer*Length of Time with Current Employer*Yearly Income*Do you have a criminal background?* Yes No Provide details and dates*IP1 Health & LifestyleDo you currently have any major medical issues?* Yes No Provide details and dates of diagnosis*Have you been tested for HIV/AIDS?* Yes No Provide date and results of most recent test*Have you ever seen a mental health professional?* Yes No Provide background and dates*Have you ever been diagnosed with depression?* Yes No Provide background and dates*Do you consume alcohol?* Yes No How often?*Do you smoke cigarettes?* Yes No How often?*IP1 Personality & InterestsPlease tell us about yourself. How would you describe your personality?*What interests do you most enjoy?*How would you describe your most positive and negative traits?*Anything you would like to share with the potential Surrogate who is reading your profile* Intended Parent 2 InformationPlace of birth*Languages spoken*Race & Ethnicity*Age*Gender* Male Female Non-binary Current occupation*Do you have a criminal background?* Yes No Provide details and dates*IP2 Health & LifestyleDo you currently have any major medical issues?* Yes No Provide details and dates of diagnosis*Have you been tested for HIV/AIDS?* Yes No Provide date and results of most recent test*Have you ever seen a mental health professional?* Yes No Provide background and dates*Have you ever been diagnosed with depression?* Yes No Provide background and dates*Do you consume alcohol?* Yes No How often?*Do you smoke cigarettes?* Yes No How often?*IP2 Personality & InterestsPlease tell us about yourself. How would you describe your personality?*What interests do you most enjoy?*How would you describe your most positive and negative traits?*Anything you would like to share with the potential Surrogate who is reading your profile* Surrogacy InformationDo you have any children?* Yes No Please share each child's age/gender*Please indicate if you carried, adopted, or utilized third-party assistance:*Check all that apply Carried Adopted Traditional Surrogacy Gestational Surrogacy Egg Donor Sperm Donor Other Please specify other*Please share why you have decided to pursue surrogacy*Have you experienced fertility issues?* Yes No Share details and dates*Please share your previous surrogacy experience, including the date(s) and relationship with your previous surrogate*What are the qualities you would like your Surrogate to have?*What reason(s) would cause you not to choose a Surrogate?*How many embryos do you plan to transfer?* One Two Undecided Will your embryos be genetically tested?* Yes No If you discovered your baby(ies) had Down’s Syndrome, would you discontinue the pregnancy?* Yes No If you discovered your baby(ies) had a severe medical condition or was terminal, would you discontinue the pregnancy?* Yes No Would you consider reducing if, due to embryo splitting, higher order multiples were conceived? (with medical recommendation factored into your decision)* Yes No How many embryo transfer attempts will you have with your Surrogate?*How much contact would you like to have with your Surrogate during the pregnancy?*Please describe anything specific you have in mind pertaining to your communication with your Surrogate, i.e. are you interested in communicating via email, text, phone or video chat? Would you like to attend any doctor appointments/ultrasounds if possible?*Would you like your Surrogate to share photos of herself/her belly with you during the pregnancy?* Yes No What do you envision for the delivery? Please specify if you would like to be in the room for the birth or any other details you want your Surrogate to know*Do you plan to remain in contact with your Surrogate after the birth?* Yes No Do you have any preference regarding post-delivery communication with your Surrogate?*Note to Potential SurrogatesPlease indicate anything additional you would like to share with potential surrogates:* Please select up to 5 photos to share with potential surrogates. These photos will help surrogates get a better sense of who you are and feel more connected to you from the start.Photo Upload Ziehe Dateien hier her oder Wähle Dateien aus Akzeptierte Dateitypen: jpeg, jpg, png, heic, Max. Dateigröße: 10 MB, Max. Dateien: 5.
