Intended Parent Questionnaire For Surrogacy Program
Thank you for taking the time to fill out our questionnaire so we can better serve you.
* Required
Name
*
This is a required question
Partner's Name
*
This is a required question
City
*
This is a required question
State
*
This is a required question
Email Address
*
This is a required question
Phone
*
This is a required question
Your Age, Partner's Age
*
This is a required question
Fertility Clinic Name
*
If you have selected one already. If not, we can provide you referrals. We have worked with over 100 IVF Clinics across the United States and we, and our clients, have our favorites.
This is a required question
Fertility Clinic City
*
This is a required question
Clinic State
*
This is a required question
Fertility Doctor
*
This is a required question
Location
*
If you require your Surrogate to live in a certain region of the country, please describe where. Keep in mind that your ability to match with a Surrogate will be greatly increased if you extend the region where she is located.
This is a required question
Insurance
*
Do you require your Surrogate to have insurance that covers Surrogacy? (If your Surrogate doesn't have insurance, a private Surrogate insurance plan could cost in excess of $20,000. Even if she does have it, deductibles could be in excess of $10,000)
Require Insurance
Don't Require Insurance
I am open to speaking with an insurance professional about private Surrogate insurance plans to determine the cost. I understand I should go over any insurance contract I buy for my Surrogate line by line with my attorney who specializes in Surrogate insurance to understand the costs and the risks and Fertility Bridges can not advise or help with insurance policies.
Other:
This is a required question
Surrogate Fee
*
We allow our Surrogates to set their own fees. Please check the Surrogate Fee boxes so we know which Surrogates to introduce you to.
$20,000
$25,000
$30,000
$35,000
$40,000
This is a required question
Infertility Issue
*
What is the nature of your infertility issue?
This is a required question
Donor?
*
If so, visit
http://www.fertilitybridges.com/list.xlsx
for a preview of our college educated donors and to obtain a password to the Donor Database.
Yes
No
Maybe
This is a required question
Egg Donor Details
We have 450 college educated Donors in our premier database of which over 100 have donated before.
Please help me a find a donor
I have already contracted with a donor
Other:
This is a required question
Do you have a surrogacy attorney?
*
If not, we can provide a referral. Keep in mind, you should still do your due diligence that the attorney is a good match for your case.
Yes
No
I would like a referral
This is a required question
Referral
*
IVF Clinic - Your clinic gave you our contact information. We will be sure to thank them.
Google Ad - You clicked one of our ads that appeared during your online search.
Online search engine - You clicked on search information results that described our company - but was not an ad.
ASRM website
Facebook - (
http://www.facebook.com/fertility.bridges
) Please visit us on Facebook.
Twitter - (
https://twitter.com/#!/fertilitybridge
) Please visit us on Twitter.
Blog - (
http://fertilitybridgesblog.com/
) Please visit our blog.
Pinterest - (
http://pinterest.com/fertilitybridge
) Please visit us on Pinterest.
Tmblr - (
http://fertilitybridges.tumblr.com
) Please visit us on Tmblr.
Chimein - (
http://chime.in/user/FertilityBridges
) Please visit us on Chimein.
Other:
This is a required question
Terms of Use
*
By submitting this form, you understand that the Fertility Bridges staff are not medical, legal or insurance professionals and information we give you should not be construed as advice. We serve as liaison between you and the medical, legal and insurance community and other fertility professionals to assist you in your Surrogacy journey. You agree to hold Fertility Bridges, and its staff harmless from any actions that might result from our communications and services we provide to you or on your behalf.
Yes, I agree to the Fertility Bridges Terms of Use
This is a required question
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