IVF Intake Application – Surrogacy Community

Name*

First Last

Age*

Date of Birth*

Marital Status*

Married
In a relationship
Single

Your partner's / spouse's name

First Last

Your partner's / spouse's age

Your partner's / spouse's date of birth

Address*

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

Email*

Enter Email Confirm Email

Phone*

How would you prefer us to contact you?*

Email
Phone

Is it OK for us to leave a voicemail on your phone if we can't reach you?*

Yes
No

Your height*

Your weight*

Your blood pressure*

Do you have any allergies? Please list them along with what kind of reaction you may have (If you know)

What contraception do you currently use?*

Please list all the medications you are currently taking. For each medication, please list the name, the dose, and the frequency. (One per line please)

Please list any vitamins / supplements you may be taking. For each item, please list the name, the dose, and the frequency. (One per line please)

Do you (or your partner) use recreational drugs?*

Yes
No

If you (or your partner) have used recreational drugs, please enter what substance(s) have been used

If you have done an IVF cycle before, please enter the following information for each cycle you have completed (one per line please): IVF Centre, # Eggs Retrieved, # Embryos Transferred, # Embryos Frozen, # PGS/PGD Normal Embryos, Outcome

Have you tried IUI before?*

Yes
No

If you have tried IUI before, how many attempts?

Has a sperm analysis been done?*

Yes
No

Has a DNA Fragmentation been done?*

Yes
No

Has any male factor issue with sperm been identified?*

Yes
No

How many times have you been pregnant?*

How many live births?*

How many vaginal deliveries?*

How many C-section deliveries?*

How many abortions have you had?*

How many miscarriages have you had?*

How many ectopic pregnancies have you had?*

How many chemical pregnancies have you had?*

Please list any complications related to the above pregnancies (if applicable)

Please list any previous surgeries you have had in the past, when and any complications that may have occurred (one per line please)

Please enter any clinical next steps / plans you have discussed with the doctor

Will you sign medical consent forms to allow our IVF nurse to access all of your medical records for review?*

Yes
No

Have you received any IVF funding for any procedures?*

Yes
No

Has the doctor reviewed the risks / complications with you regarding the procedure?*

Yes
No

Are you satisfied with the care you are receiving?*

Yes
No

Are you looking for a second medical opinion?*

Yes
No

Do you feel you have been an active part of your fertility plan? Please explain*

Have you tried any of the following holistic procedures?*

Acupuncture
Chinese Herbs
Osteopath Treatments
Naturopath Treatments
None of the above

Are you being followed by any other specialists for any related or unrelated medical reasons?*

Yes
No

If yes, please list in detail

Has an egg or sperm donor been considered or suggested by your fertility physician?*

Yes
No

Please list any further questions you may have (one per line please)

What do you envision for your Support Plan with us?*

Once the submit button is pressed the word "Processing" will appear. Your application has been submitted and Canadian Surrogacy Community will be in touch. Thank you for your submission.

IVF Intake Form