Intended Parent Matching Questionnaire

Thank you for taking the time to complete the Intended Parent – Surrogate Matching Questionnaire. Your answers to these questions are strictly confidential and will never be shared with potential surrogates. Please answer each question as fully and as thoughtfully as possible. Your answers will help us understand your expectations moving forward as well as help us properly match you with your gestational carrier.

Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth(Required)

MM slash DD slash YYYY

Country of Citizenship(Required)

Relationship Status(Required)

Married

Single

Divorced

Separated

Partnered

Spouse/Partner Name

if applicable

First Last

Spouse/Partner Email

If applicable

Spouse/Partner Phone

If applicable

Spouse/Partner Date of Birth

If applicable

MM slash DD slash YYYY

Do you identify as:(Required)

Heterosexual

LGBTQIA+

Other

IVF Clinic Name(Required)

IVF Physician Name(Required)

How many embryos do you have available to transfer?(Required)

I have not yet created any embryos

Have your embryos undergone PGT-A?(Required)

Formerly referred to as PGS

Yes

Have not yet created embryos, but plan to test

Have not yet created embryos and do not plan to test

Genetic Contributor Information(Required)

Please check all that apply

Used a sperm donor

Used an egg donor

Did not use any donor material

Do you already have children?(Required)

Yes

Have any of the persons who contributed genetic material in the creation of your embryos ever been diagnosed or currently have HIV?(Required)

Yes

Do you acknowledge that Elevate does not facilitate surrogate matches for double embryo transfer?(Required)

Double Embryo Transfer (DET) is the practice of transferring two embryos during a single transfer cycle in the hopes of achieving a twin pregnancy. – This is not related to additional transfers following a failed embryo transfer.

Yes

Ideally, when would you like to transfer an embryo, or embryos to your surrogate?(Required)

MM slash DD slash YYYY

What kind of relationship are you hoping to have with your surrogate?(Required)

Are you interested in learning more about and/or meeting your surrogate's family (spouse/children)?(Required)

Yes

Would you be interested in receiving breast milk from your surrogate after the birth?(Required)

Yes

Have you spoken with your own family members about your desire to use a surrogate to expand your family?(Required)

Yes

If yes to the previous question, does your family support you? Do they have any reservations?(Required)

Do you plan on telling your future child that he/she was born through a surrogate mother?(Required)

Yes

If it is determined that there is a physiological malformation of your child, would you want to terminate the pregnancy?

Please check all that apply

Most likely Yes

Most likely No

Absolutely Yes

Absolutely No

Would you want selective reduction in the case of more than twins?(Required)

Please note: MORE than twins. If you are an international intended parent, please be aware there is currently no insurance policy that will cover the surrogate or newborns in the case of triplets.

Yes

If medically possible, would you require a selective reduction in the case of twins?(Required)

Yes

Regarding the previous three questions, please give us more insight regarding your general thoughts toward termination/abortion as it may relate to your surrogacy journey.(Required)

Do you have a specific compensation range in mind for your surrogate? If so, please us the range.(Required)

On the low end, first-time Surrogate compensations begin at $55k.

What is your profession?(Required)

Please include spouse/partner’s profession as well if applicable

What are your hobbies and interests outside of work?(Required)

Do you have any religious affiliation?(Required)

Are you looking for a surrogate in a certain part of the United States?(Required)

Northeast US

Southeast US

Midwest US

Southwest US

West Coast US

No preference

How important is it that your surrogate is located near you?(Required)

Not important

Slightly important

Important

Very important

Extremely important

How important is it that you are able to attend your surrogate's OBGYN appointments?(Required)

Please note that all Elevate Surrogates agree to FaceTime/Skype (as allowed) for OBGYN/ultrasound appointments if you are not able to attend.

Not important

Slightly important

Important

Very important

Extremely important

How important is a surrogate with a specific religious affiliation?(Required)

Not important

Slightly important

Important

Very important

Extremely important

Would you make any special requests of your surrogate while she is pregnant? Please explain.(Required)

Special diet, breast milk, weekly phone calls, etc.

What is most important to you?(Required)

Timing

Location of Surrogate

Surrogate Compensation

Personal Connection to Surrogate

Please describe your dream surrogate.(Required)

Please list any other preferences you may have relating to the surrogacy process.

All Elevate Surrogates have passed our rigorous screening process, exceeded ASRM guidelines, passed background checks and have proven commitment to becoming a gestational carrier. We accept all candidates who meet our stringent guidelines, regardless of ethnicity. If you would not accept or be displeased with a surrogate of a certain ethnicity, please let us know.

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