Surrogate Information Form

SURROGATE INFORMATION FORM

This Surrogate Information Form is made and entered into by and between Surrogate Name: and Intended Parent(s) Name(s): on this date: .

RECITALS

WHEREAS, Intended Parent(s) desire to engage Surrogate to carry and deliver a child on behalf of Intended Parent(s) pursuant to a separate Surrogacy Agreement and to obtain comprehensive information regarding Surrogate's medical, obstetric, legal and social history; and

WHEREAS, Surrogate agrees to provide accurate and complete information for the purposes of medical evaluation, legal review, insurance coordination and to assist the parties and their respective medical care providers in making informed decisions; and

WHEREAS, the parties acknowledge that certain disclosures provided herein may be relied upon by medical providers, attorneys, insurers and agencies in determining eligibility and suitability to proceed with the contemplated assisted reproductive procedures.

NOW, THEREFORE, in consideration of the mutual covenants and representations contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. SURROGATE IDENTIFICATION

Date of Birth:    Place of Birth:

Primary Phone:    Email:

2. PARTNER / SPOUSE INFORMATION

Relationship to Surrogate:    Contact Phone:

3. MEDICAL AND OBSTETRIC HISTORY

Number of live births:    Number of miscarriages:    Prior cesarean deliveries:

4. INFECTIOUS DISEASES, MEDICATIONS, AND SUBSTANCE USE

Current medications (prescription and over-the-counter):

Tobacco use: Yes    Alcohol use within past 12 months: Yes    Illicit drug use within past 24 months: Yes

5. LEGAL AND SOCIAL HISTORY

Have you ever been convicted of a felony? Yes    Are there pending legal actions involving you? Yes

6. INSURANCE, EMPLOYMENT AND FINANCIAL

Health Insurance Carrier:    Policy Number:

Anticipated Base Compensation Amount:

7. AUTHORIZATIONS AND CONSENTS

By checking the boxes below, Surrogate authorizes the following actions to be taken by medical providers, intended parents' agents, and their authorized representatives:

Consent to necessary medical care and procedures related to the pregnancy and delivery as determined by treating physicians.
Consent to release medical records related to fertility treatment, prenatal care, delivery and postpartum care to Intended Parent(s) and counsel as required.
Consent to genetic, infectious disease and drug testing as reasonably requested in connection with the surrogacy process.
Consent to background checks and criminal history checks as required for eligibility.

8. REPRESENTATIONS, WARRANTIES AND COVENANTS

Surrogate represents and warrants that: (a) Surrogate is at least eighteen (18) years of age, legally competent to execute this Form and to participate in the surrogacy process; (b) all information provided in this Form is true, complete and correct to the best of Surrogate's knowledge and belief, and Surrogate has disclosed all material medical and legal facts; (c) Surrogate will promptly notify Intended Parent(s) and their counsel of any material changes to the information contained herein, including but not limited to medical conditions, substance use, or legal proceedings.

Intended Parent(s) represent and warrant that they will provide accurate information to Surrogate, will cooperate in arrangements for medical care and insurance coordination, and will not interfere with Surrogate's reasonable medical care and decision-making during the course of the pregnancy.

9. CONFIDENTIALITY

All parties agree that information disclosed in this Form and any related medical records, social histories and background checks are confidential and shall not be disclosed except as necessary for medical care, legal review, insurance purposes, or as required by law. Notwithstanding the foregoing, the parties may disclose confidential information to their attorneys, medical providers and other advisors who have a need to know and are bound to confidentiality.

10. NOTICES

All notices required or permitted under this Form shall be in writing and delivered to the addresses set forth below:

11. AMENDMENT; WAIVER; COUNTERPARTS

This Form may be amended only by a written instrument executed by all parties. No waiver of any provision of this Form shall be effective unless in writing and signed by the party waiving compliance. This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

12. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

Governing Law: This Form shall be governed by and construed in accordance with the substantive laws of the state specified in the Surrogacy Agreement executed by the parties or, if no state is specified therein, by the laws of the state in which the principal medical treatment is to occur.

Entire Agreement: This Form, together with any attachments and the controlling Surrogacy Agreement between the parties, constitutes the entire understanding between the parties with respect to the subject matter herein and supersedes all prior discussions and agreements.

Severability: If any provision of this Form is held invalid or unenforceable, the remainder of this Form shall remain in full force and effect and such invalid or unenforceable provision shall be replaced by a valid and enforceable provision that most closely reflects the parties' original intent.

13. CERTIFICATION

By signing below, Surrogate certifies under penalty of perjury that the information provided in this Surrogate Information Form is true, complete and correct to the best of Surrogate's knowledge, and acknowledges that intentional material misrepresentation may constitute grounds for disqualification from participation in the surrogacy process and may subject Surrogate to legal consequences.

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