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PROSPECTIVE PARENTS’ INQUIRY FORM

Qualification Requirements: Married (or in a long-term, committed relationship), heterosexual, have a stable relationship, both partners must be committed to pursuing parenthood through third party-assisted reproduction, and one of the couple must be under 55 years of age.

Please take a few minutes to complete this form, which will help us to know how we may be of assistance to you. A Baby Miracles representative will contact you within 48 hours.
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Your Name:
Your Spouse/Partner's Name:
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Your Age:
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How did you hear about us?
What is the reason you need a Fertility Assistant?
How soon will you be ready to begin?
What type of Fertility Assistant are you interested in? (check all that apply) Gestational Surrogate  Traditional Surrogate  Egg Donor
If you require a surrogate, what qualities do you find most important?
If you require a traditional surrogate or egg donor, what is your criteria, i.e. age, height, weight, location, etc.?
Are you currently working with a clinic and, if so, which one?
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