Contact

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Click Here Apply For Surrogate

Please. Fill out completely, thoroughly, and truthfully, potential recipients will be reading this application (identifying information will be masked).

SURROGATE APPLICATION FORM

Please state your fee

What will your fee be used for ?

Please rate from 1 to 10 how important the following factors were to you in making your decision to be a surrogate mother ( 1=least important; 10=most important).

I like being pregnant but don’t want more children of my own.

I need the money very much.

I think people who want children should have them.

Giving someone else a child would make me very happy.

Other (please explain ) :

How did you become aware of the Aesc International Medical Consulting Inc. :

Newspaper advertisement Specify:

Newspaper / magazine article Specify:

Friend / acquaintance Name:

Other

AUTHORIZATION FOR RELEASE OF INFORMATION

(Civil Code section 56.10)

TO: ANY PHYSICIAN, MEDICAL FACILITY, PSYCHIATRIST, PSYCHOLOGIST, OR OTHER HEALTH CARE OR MENTAL HEALTH PROFESSIONAL:

YOU ARE HEREBY AUTHORIZED to release to BabyDream Surrogacy Inc. any and all medical, psychological, psychiatric, or health information pertaining to me, or to my pregnancy, or to the child expected to be born on or about _________________ which is now or in the future may be in your possession or under your control.

BabyDream Surrogacy Inc. is expressly any and all horized hereby to copy, or receive copies of, any records or documents pertaining to me or the information specified above, and to distribute said copies to _____________________________( Prospective Parents) or to any other Prospective Parents and to any other interested physician, psychiatrist, psychologist or health care or mental health professional who requires the information for purposes of medical or psychological assessment or treatment.

The information may be used in, or in connection with, the surrogate parenting agreement I entered into with the Prospective Parents identified above or with other Prospective Parents.

This authorization shall remain valid for two years from the date hereof.

I have been advised of my right to receive a copy of this Authorization.

I have received a copy of this Authorization.

Yes

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Dated:

Surrogate

HUSBAND/PARTNER SUPPORT FORM

I am _______________________________________________, the husband/partner of _____________________________. I can/cannot attend the initial interview that you have scheduled for my wife/partner on ______________________.

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Choose

I am supportive of my wife's/partner's decision to be a surrogate mother to help an infertile couple have a child.

I am not supportive of my wife's/partner's decision to be a surrogate mother to help an infertile couple have a child.

I am willing to have an HIV test.