Initial Intake Form

1Personal Information
2Prequalification Checklist

First Name

Last Name

Street Address

City

Country

State

Zip Code

Phone Number

Best time to call

May we leave a voicemail at this number?

How would you prefer to be contacted?

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

What is your height?

What is your current weight?

lbs

How did you hear about our agency?

Have you given birth?

I want to be a surrogate mother.

I do not use recreational drugs.

I am in excellent health.

I am a non-smoker and live in a smoke-free household.

I understand that I cannot be a surrogate mother at this time if I have had tattoos or body piercings within the past six months.

I have a flexible schedule and can attend several medical appointments for my participation in a surrogate mother cycle with notice.

I am willing to self inject medications with proper instruction for a period of 1-4 weeks for my participation in a gestational surrogacy cycle.

I am aware of the medical psychological risks associated with gestational surrogacy.

Do you and your spouse understand that agreeing to be a surrogate mother is a serious commitment? It may take several months to find the right match and once matched the process requires a 12--18 month commitment on average.

I understand that Happy Beginnings, LLC, prospective Intended Parents and other professionals will rely upon the information contained in my Application and I agree to answer each question completely and truthfully.

I understand that Happy Beginnings, LLC does not and will not provide information or advice on legal, medical, genetic, or psychological advice on the risks involved in the gestational surrogacy process.

I agree to release Happy Beginnings, LLC and hold it harmless from any and all responsibility or liability with respect to any and all risks associated with the legal, medical, genetic, and/or psychological aspects of the gestational surrogacy process.

By submitting this questionnaire, I agree that I represent that all written representations and information provided and/or to be provided , are true, correct and complete.

I agree to the terms of service