Intended Parent Questionnaire For Surrogacy Program

Name

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Partner's Name

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City

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State

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Email Address

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Phone

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Your Age, Partner's Age

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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.

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Fertility Clinic City

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Clinic State

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Fertility Doctor

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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:

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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.

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Infertility Issue

What is the nature of your infertility issue?

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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

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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:

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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

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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

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