California PBO Intake Form (Agency or GC)

Your Name and Email:

Surrogate’s Full Legal Name:

Is Surrogate Married?

Yes

Surrogate’s Husband/ Partner’s Full Legal Name (First, Middle, Last):

Surrogate’s Current Residential Address:

Surrogate’s County of Residence:

Number of Embryos Transferred:

Number of Child(ren) the Surrogate is Carrying:

Expected Due Date:

Embryo Transfer Date:

Name of Physician who Actually Performed the Embryo Transfer Procedure:

Clinic Name:

IVF Coordinator Name and Email

Clinic Address:

Clinic Phone Number:

Date of Confirmation of Pregnancy (heartbeat):

Name of attorney for Gestational Carrier:

Name of Hospital where the Surrogate is Expected to Give Birth to the Child(ren):

Hospital Address:

Hospital Telephone Number:

Surrogate’s Medical Insurance:

Has Gestational Surrogacy Agreement been sent to lien company, if applicable?