Intended Parents Profile Intended Parents Profile Form Step 1 of 12 - Intended Parent & Spouse/Partner Background 8% Name First Last AgeCounty State/Province Country Occupation Educational Background Do you have any previous children? Yes No What language(s) do you Speak? Where did you grow up and what was your childhood like?What are your current religious beliefs? What is your favorite color? What is your favorite movie or TV show? What is your favorite food What is the best book you have read in the last 5 years? What is your favorite thing about yourself? Who is the most important person in your life and why? Who lives in your home with you? Do you have any health -related issues or problems? How do you spend your free time? What do you feel most passionate about? What do you value most in life? What do you believe are the most important qualities a parent can possess? What has been the most difficult aspect for you in arriving at this decision to use a surrogate? How do you envision your life changing once you have a child? Is there any other information you would like to share with your surrogate? Name First Last AgeCounty State/Province Country Occupation Educational Background Do you have any previous children? Yes No What language(s) do you Speak? Where did you grow up and what was your childhood like?What are your current religious beliefs? What is your favorite color? What is your favorite movie or TV show? What is your favorite food What is the best book you have read in the last 5 years? What is your favorite thing about yourself? Who is the most important person in your life and why? Who lives in your home with you? Do you have any health -related issues or problems? How do you spend your free time? What do you feel most passionate about? What do you value most in life? What do you believe are the most important qualities a parent can possess? What has been the most difficult aspect for you in arriving at this decision to use a surrogate? How do you envision your life changing once you have a child? Is there any other information you would like to share with your surrogate? Detail how long you have been trying to have a baby and what brings you to surrogacy:In what city /state is your fertility clinic located? Where will your surrogate be traveling for the embryo transfer? Have you already created embryos? Yes No In in the process, when do you expect to have embryos? How many embryos do you have?In what year were they frozen? MM slash DD slash YYYY Were they created using donor egg? Yes No If so, age of the egg donor at the time of retrievalAre you planning a single embryo transfer? Yes No How many frozen embryo transfers are you willing to attempt with a surrogate?Have you had Preimplantation Genetic Testing (PGT) performed on your embryos? Yes No If not, are you planning to test your embryos in the future? Yes No Has the sperm or egg source tested positive for HIV or Hepatitis? Yes No Is there any additional information you would like to share?What is your reason for using a surrogate? Please detail what is most important to you in selecting a surrogate:What qualities would you like to see in your surrogate? Are you open to working with a surrogate in another state? Yes No Would you prefer a surrogate who is married? Yes No How do you plan to communicate with your surrogate?emailTextphoneAll of the aboveHow much contact would you like to have with your surrogate? Please describe how you envision your ideal relationship with your surrogate during the pregnancy.how much contact do you foresee having with your surrogate after the birth? Would you be willing to share photos of the baby (babies) with your surrogate? Yes No Are you willing to meet your surrogate's children? Yes No Do you intend to tell your child (children) about your surrogate one day? Yes No If you have children currently, will you be introducing your surrogate to them? Yes No How do you fell about your surrogate carrying a twin pregnancy? Should a higher order multiple prgnancy occur, would you choose for your surrogate to undergo a fetal reduction? Yes No Would you ask your surrogate to have an amniocentesis or CVS? Yes No Would you choose to have the pregnancy terminated if there were a severe abnormality? Yes No If yes, please detail what you consider a severe abnormalityDo you intend on physically or virtually attending OB appointments with your surrogate? Yes No Would you consider allowing your surrogate to spend time with the baby (babies) at the hospital before going home? Yes No Please take this opportunity to write a letter and provide pictures to the surrogate who will be reviewing your profile.FileMax. file size: 100 MB. By signing below, I/we assert that the information stated above is accurate and truthful. I/we agree to submit this application, Intended Parent Profile, and pictures. I/we authorize LPSFC to release the information provided in this document, unless otherwise noted, to potential surrogate candidates for review and consideration. I Accept I do not accept Les Petits Surrogacy and Fertility Consulting is committed to protecting and respecting your privacy. We will only use your personal information to provide the products and services you requested from us. We would like to contact you with information regarding your surrogacy / fertility journey. By checking this box, I/we give express written consent for LPSFC to call, text, or email regarding services abut which I/we have inquired. I agree to LPSFC Privacy Policy. I agree to recieve communications from LPSFC Signature - Intended ParentDate Month Day Year Name First Last Signature - Intended Parent Spouse/PartnerDate Month Day Year PhoneThis field is for validation purposes and should be left unchanged.
