Intended Parents Registration Form

Intended Parents Surrogacy Registration Form
Please complete the questionnaire below. After filling in all required fields, please submit the form. A member of our fertility consulting team will contact you with the next steps. You can also save this form and return to complete the unanswered questions later.

1. Choose your surrogate plan:

2. Timing to Begin

I. Personal information – Wife

Name

First

Last

Family name:

First

Last

Passport #

Issuance country

Expiration Date

Mobile Number

Date of Birth

Age

Address Street

Address Line 1

City

State / Province / Region

Postal Code

Country

II. General Questions

2.1. What is the medical reason for the necessity of surrogacy?

Please specify

2.2. When were you first diagnosed with this condition?

Do you have a State-issued certificate of marriage?

The Ukrainian Ministry of Health requires us to receive a letter detailing the medical contraindications for surrogacy. This letter must be issued by a licensed medical professional, printed on official letterhead, and bear their signature and stamp. Once we receive this document, we can confirm your acceptance into our surrogate program.

2.3. How long have you been legally married?

2.4. Do you have children?

2.5. Was your pregnancy the result of

4.12. screening if

III. Personal Information -Husband

Name

First

Last

Family name

First

Last

Passport #

Issuance country

Expiration Date:

Date of Birth

Mobile Number

Age

Address Street

Address Line 1

City

State / Province / Region

Postal Code

Country

IV. General Questions

4.1. Do you have children from a previous marriage?

4.2. When was your most recent semen analysis?

4.3. Do you know if anyone in your family has a hereditary disorder?

4.4. If yes, do you know which disorder(s)

4.5. If yes, please specify which one(s)

4.6. Have you undergone a comprehensive genetic carrier screening test?

4.7. Would you be willing to undergo an expanded carrier screening test?

It is not mandatory; however, conducting the extended carrier test is recommended when utilizing an egg donor. If you are identified as a carrier, the egg donor must undergo genetic sequencing for the same mutations to reduce the risk of passing them on to your newborn.

4.8. Are you presently taking any prescription medications?

4.9. If so, could you please specify which ones?

It is recommended that you speak with the physician who prescribed your medication if you are taking prescription drugs and have an upcoming semen analysis or plan to provide a semen sample for fertilization.

4.10. Do you smoke?

4.11. If yes, what do you smoke?

Tobacco and cannabis use has been associated with a decline in semen quality, impacting various factors such as semen volume, sperm count, motility, viability, and morphology. Additionally, smokers may experience lower levels of reproductive hormones, challenges in sperm production, issues with sperm maturation, and diminished sperm functionality.

To achieve optimal outcomes, it is essential to refrain from cannabis smoking for at least ninety (90) days before a semen analysis or initiating any assisted reproductive procedures that involve your sperm. The duration for cannabis to be eliminated from your system varies based on the frequency and duration of use.

4.12. Do you drink alcohol?

4.13. How often do you drink?

Alcohol consumption is associated with sexual dysfunction, and studies indicate that it may lower both sperm count and sperm quality—two elements that can be assessed through a semen analysis.

For further information on preparing for a semen analysis, we recommend consulting our Donor-Assisted Conception Handbook, available here. The pertinent information is in Chapter Two, covering pages 37 to 44.

We encourage you to contact your dedicated fertility consultant at Embryon, who is committed to supporting you throughout your journey. Your consultant possesses the necessary knowledge and expertise to assist you in your preparations and address any questions or concerns. The entire Embryon team is available to assist you throughout every phase. Reach out to us so you are fully prepared to embark on your journey with us.

Privacy & Data Protection
We prioritize your privacy and the protection of your personal information. Any data you provide will be kept confidential and used solely for internal purposes, without sharing it with outside parties.
Embryon and the Institute for Reproductive Medicine are dedicated to safeguarding your sensitive data and implementing strict measures to prevent external access. We are committed to maintaining your trust and protecting your privacy.

The Embryon Family

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