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Central Coast Surrogacy, LLCbuilding family together
Mail: PO Box 6659. Santa Maria. CA. 93456Office: 805-314-2918..... Fax: 805-980-4459
www.CentralCoastSurrogacy.com
Introductory Package
Egg Donor and Surrogate
Domestic andTravel Abroad Program
toBeijing, China
and Saipan
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Dear Egg Donor/Surrogate,
Thank you so much for choosing to open your heart with Central Coast Surrogacy, LLC as your agency. We understand the struggle that many couples have had to overcome to get this far and are proud that you have taken the next step in helping them to realize their dream of expanding their fam-ily. It takes a warm and caring soul to become an Egg Donor and/or Surrogate.
Central Coast Surrogacy, LLC is a full service agency, providing many services and resources to assist all families. We assist Intended Parents in the selection of an Egg Donor and/or Surrogate, insurance/broker for their Surrogate, IVF clinic selection, monitoring facilities for their Surrogate, attorney for you and your Intended Parents, Psychologist, background clearances, and case management throughout the process for both you and your Intended Parent’s. As a prior Egg Donor and Surrogate myself, I hope to help you through this process with ease and understanding. I have many connections in the field of assisted reproduction as well, who will be more than happy to assist as needed.
As some of my clients know, I have spent the past 20 years helping families. I began working with chil-dren and counseling families, obtaining a master’s degree in Psychology, and have since found my pas-sion. As a Surrogate mother I realized that there are many families struggling to feel complete, and I had the tools and resources needed to help them. I have made this my life mission. To help empower woman through Egg Donation, Surrogacy, and creating their family.
Central Coast Surrogacy, LLC has helped many couples, including International families, add special additions to their home. Some families are local to the United States, while others are from countries, such as: China, Italy, Germany, and the UK. Our Surrogates are based in the United States, but our Par-ents are from around the world.
This packet will explain many of the basic information about the process and travel, but you may also like us on facebook or visit us at www.CentralCoastSurrogacy.com
When filling out forms and profiles, or printing release, please feel free to copy and paste into a sepa-rate word doc for ease of use.
Please feel free to call, text, wechat, or email me at [email protected] with any questions or concerns. I look forward to working with you during this journey.
Sincerely,
Danielle Hernandez, PhDFounderCentral Coast Surrogacy, LLCWechat: momdanielle805-714-1919 phone805-980-4459 fax
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Contents:
Travel Abroad Program…………………………………………………………..4
Services Provided:...................................................................................................8
Criteria, Fee Schedule, and Process for Egg Donors:..............................................9
Criteria, Fee Schedule, and Process for Surrogates:..................................................12
Injection Instructions………………………………………………………………15
Egg Donor Agreement:............................................................................................21
Surrogacy Agreement:.............................................................................................25
Medical Records Release Form................................................................................27
Application…………………………………………………………………………30
Egg Donor/Surrogate Profile:...................................................................................32
Next Steps.................................................................................................................39
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Travel Abroad Program in Beijing, China and Saipan
Why Travel Abroad?
We are proud to be the only agency to offer to our Surrogates the opportunity to travel abroad and learn about another culture, the culture where your Surrogate Baby will return to shortly after birth. This is important to some of our Intended Parents as they are able to continue to work through the transfer process and have an opportunity to meet with their Surrogate in person prior to transfer, and it also al-lows for them to stay with the same Doctor they have been seeing for infertility. Our travel abroad Egg Donors and Surrogates will be following the same routine and procedures as our US based Egg Donors and Surrogates, but will be able to have a paid trip to meet with their Intended Parents IVF Doctors at the Pacific Fertility Institute in either Saipan or Beijing, China and travel and tour a new part of the world. These Egg Donors and Surrogates are typically away from home 7-14 days and receive all the compensations associated with travel in their contracts, including child care reimbursements as needed, mileage reimbursements, passports and visas reimbursed, food allowance, hotel accommodations and lost wages. As with other types of employments, benefits are for the surrogate only. Family members wishing to travel with the surrogate would be responsible for their own travel expenses.
Frequently Asked Questions About Travel:
I’ve never traveled before. Is this ok?Yes! Most of our Egg Donors and Surrogates traveling abroad have never traveled out of country be-fore. That’s what makes this program so special. We will help you to obtain your passport and visa prior to travel, schedule your flight and accommodations, and help you each step of the way. Travel out of country can be a scary thought, but we have bilingual staff in Beijing through the clinic who will ar-range airport pick up and hotel drop off and staff at our clinic there will be able to assist you as well. The hotel we use in Beijing also has bilingual staff and can help you to schedule a taxi to what tourist sites you are interested in seeing. Saipan is a territory of the USA and is English speaking.
How much does it cost to travel abroad?It costs our Donors and Surrogates no out of pocket money to travel abroad. All expenses are either paid for ahead of time or are able to be reimbursed. This includes payment for medications, transfer, lost wages, food allowance, mileage, hotel airfare, passport, visa, ect. There may be a time when you choose to do an activity on your own, or buy your children souvenirs; this is ok and can at your ex-pense, but no part of the Surrogacy process will be at your cost.
I will miss my family Can I communicate with them?Yes! You are welcome to use your cell phone or the hotel phone to call home. You can also bring your laptop or kindle and connect via the hotel wifi to skype or email. I personally use my cell phone and can still access my facebook, email, and wechat my family while I travel abroad.
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Will I be able to reach someone from my agency if I have a question or need help?Yes! We are always here to help our Donors and Surrogates. We will set up a plan and communication schedule based on your method of communication. Our Director always has access to her cell phone, email, facebook, skype and wechat accounts, which you will have access to. As well as bilingual staff in Beijing.
Is Beijing a safe place to explore?Beijing China is a safe place to explore. We have traveled there several times with Surrogates and have had great experiences each time. He people of Beijing are kind and happy to see Americans wanting to explore and learn language and culture. The crime rate in Beijing is low and there are visible law offi-cers around. Please exercise normal cautions, such as not traveling alone at night or going anywhere alone with a stranger to be safe and be cognizant of your surroundings.
What is the flight like?Long! The flight to Saipan and Beijing can be anywhere from 14 hours to 18 hours. We try to book straight through flights when possible, but lay overs can be unavoidable at times. We recommend bringing a book or an activity you like to do, dressing comfortably to allow for sleeping, and layer your clothing. Meals are served in flight and you are allowed to walk isles and use the restroom. Most flights also have movies, tv shows, and games on the seat backs.
Are the hotels in Beijing normal?Love this question. Yes they are, toilets too. We book at modern westernized hotels, they look just like ours here in the US. A common hotel we use is Holiday Inn Express Beijing. It has a kitchen around the clock, laundry facility, English TV channels, a currency exchange machine, gym, lounge, a business center, and English speaking staff to help you at any time.
What is the schedule like?Typically Surrogates and Donors will already be contacted and started on their fertility medication prior to leaving the US. The first day you will be able to rest and set up your hotel room. The following day
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you will meet at the IVF Clinic to have your labs and check your uterine lining or follicles. If all looks well then transfer will be scheduled for 3-4 days after and then bed rest at the hotel for the next 24 hours. After this, you will be able to resume moderate walking and go home 1-2 days after. If your lin-ing is not quite ready for transfer, your doctor will adjust your medications and check again in 2-3 days. The first 4 days (or longer if your lining is not quite ready) you will be able to pick what activities/sites you would like to see. After transfer most Surrogates stay near to the hotel and mostly rest before flight home.What is there to do?The hotel will have some activities, like the gym, business center, and TV for your spare time. Sites to see and culture are the best part. While there it is nice to see the Beijing Zoo, the Great Wall, the For-bidden City, Temple of Heaven, Summer Palace, Silk Market (name brand items for less), Ming Tombs, Lama Temple, just to name a few.
Tips For Travel
1. Prior to your trip, order a type 1 China plug adaptor from Amazon. This will allow you to plug in and charge your devices. We recently bought a 3-pack for $7.
2. Prior to your trip check out what the weather will be like. It is ok to pack less clothing and wash at the hotel. You may find some great things to wear while there, so leave room in your suit-case.
3. Prior to travel notify your cell phone carrier of your travel and ask to add an International pack-age to your plan. Also, notify your bank and credit card company.
4. Remember to print out and take your medication calendar and your medications with you in your suit case.
5. Limit the amount of liquids in your carry on. I always pack a small pack of wipies, tissues, a tooth brush and tooth paste, and a small travel size face wash.
6. Arrive at the airport 3 hours before your flight. That way you can make sure to get to the cor-rect International Boarding area and wait through the line and get through customs with time to spare.
7. Upon arrival, take your time. You will need to fill out a card on board for customs and have this and your passport ready to exit the airport. It is easier to keep these in hand or at least some-where with easy access.
8. The airport should have a currency exchange. There is a fee for exchanging currency. I usually will carry cash and exchange in the Beijing Airport. Some hotels and street markets also have exchange sites.
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9. Once you get to your hotel unpack and relax. Then explore it! Check out what amenities are available to you. Enjoy and relax!
10. Have the Hotel staff write on a business card in Chinese where you are going and have them call your Taxi. This will make it easy to show your driver where you want to go and then you will also have the return address on the card. Pay attention to your Taxi color. It will be the same color Taxi you will need to get back.
11. There is a large time difference. Ease yourself in to the new schedule. Be ready to need a short nap in the late afternoon. This is normal. It’s also normal to be wide awake at 3am.
12. Do not be afraid to ask your clinic questions about everything; from food, to culture, to medi-cations, to transfer, to tour guides. They have a Public Relations person who will spend some time with you and show you the ropes.
13. Take tissues with you everywhere! Not all bathrooms have toilet paper.14. If you like spicy food, there is no spicy like China spicy. It will knock your socks off. If you don’t,
stay away!!15. Never go anywhere with anyone you do not know. Stay in crowded areas with others to be
safe.16. If meeting your Intended Parents is part of the plan, do not be nervous! They are just as anx-
ious as you are 17. If you have any questions after transfer, do not be afraid to ask. If you need anything while on
bed rest, do not be afraid to ask. We are all here to help and support you. There are staff living near the hotel and clinic available to you at all times.
18. Transportation back to the airport will be arranged for you. It will come 3 hours before your flight leaves. Be packed and have your passport ready prior to leaving.
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Services Provided:
1st Initial Consultation with Intended Parents/Donors/Surrogate. This consultation is important so that we may understand where you are coming from and where you are planning to go. It will ad-dress any concerns, any needed information, and provide you with an understanding of the process ahead of you.
2nd Assist in IP selection of an Egg Donor and/or Surrogate. We have a wide selection of In-tended Parents. We will inquire and learn about you and help you in finding a match that feels right. No matter the length of time required, we will assist in matching. We will immediately notify of any Intended Parents showing interest. Your profile will be made available as soon as it is complete.
3rd Assist Surrogate in Insurance Review. Central Coast Surrogacy will have your health insurance policy reviewed for coverage and will assist in assigning a broker to help you maintain insurance for your pregnancy.
4th Egg Donor and Surrogate Screenings. Our Egg Donors and Surrogates are all background cleared and receive a Psychological clearance from trained counselors in the field. You will provide us with recent medical clearances and prior pregnancy/birth records and a medical clearance form, to en-sure good health. Egg Donors and Surrogates must meet certain criteria to qualify.
5th Locate separate Legal Counsel for Egg Donor/Surrogate and Intended Parent. Each party in-volved in Surrogacy will be afforded their own attorney at the expense of the Intended Parent and are paid upfront for their time. Counsel will be responsible for the legal aspects of the contracts and paternity rights and filings. We have several attorneys experienced in surrogacy law who assist us in these matters.
6th Set up Escrow Account. It is necessary to have a third party company handle funds for your Surro-gate expenses and bills related to Surrogacy. We take the worry out of this step, by setting up es-crow with agencies known for their professionalism in the field of accounting as related to Surro-gacy.
7th Coordinate appointments as needed. Central Coast Surrogacy, LLC will be case managing and relaying information to the doctor, attorney, escrow company, and Intended Parents. Many times a Surrogate or Donor is better able to communicate directly with her IVF Dr, but as needed or re-quested, we are happy to assist in appointment scheduling, travel accommodations, or finding mon-itoring sites close to your home.
8th Contract with Agency. Central Coast Surrogacy, LLC will provide you with a contract between you and our agency and also an estimated fee sheet. This is a guideline of services provided, gen-eral issues and concerns, and an introduction. You are welcome to take your time reviewing this and can also have your attorney read this as well.
9th Attend appointments as requested. Central Coast Surrogacy, LLC is happy to attend appoint-ments as requested when possible and provide Intended Parents with feedback and pictures.
10th Arrange Accommodations. As needed, Central Coast Surrogacy, LLC will assist in booking hotels and helping find flights for Surrogates, Donors, and Intended Parents.
11th Support Surrogate and Intended Parents through resolution. Should conflict or concern arise, we will assist each person through resolution to make this a smooth and beautiful experience for everyone.
12th Attend Delivery. Central Coast Surrogacy, LLC makes every effort to attend delivery or visit shortly thereafter with approval from the Intend Parent. There may be issues, such as distance or conflicting appointments that prevent this, but communication will always be made available.
13th Counseling. As needed, we will assist in helping your Surrogate and Donor transfer back into her role as a wife and mother. If necessary, we will refer her to groups, forums, or counseling ser-vices.
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Criteria For Egg Donors:
Be between the ages of 18-29 years, can be older for Asian donors No family history of serious medical problems or psychological disorders Be of good health currently Maintain a healthy BMI (under 30) and lifestyle Have a stable residence Be willing to undergo medical and psychology screening and background clearances Be able and willing to make all necessary appointments Be willing to show proof of current academic achievement, degree, and employment
Fee Schedule: Egg Donors earn anywhere from $5,000 and up First time Egg Donors typically earn less than proven Egg Donors Egg Donors with exceptional qualities, advanced degrees, particular ethnicity, ect. typically
earn more
Process:
Apply on-line at CentralCoastSurrogacy.com or through your case manager Complete Egg Donor Profile with pictures of yourself at several different ages and some of im-
mediate family members. Remember that clear pictures, labeled, will be best for being selected. Some questions on your application and profile may not apply, mark “NA”. Never let any ques-tion remain blank. Take Medical Record Request form to your OB/primary doctor to obtain your latest physical/pap smear results.
Sign and return Egg Donor Agreement Submit a copy of your driver license and health insurance card Submit any transcripts or awards you would like to be considered Submit your last 3 paystubs to determine lost wages Begin matching process Psychological Screening Legal Contracting with Intended Parents IVF Clinic Clearance Begin medications as directed and schedule Retrieval* Some Egg Donors are selected several times, while others are never selected.
These are the standard steps in the process and the risks:
Stopping your normal cycle: You may be prescribed a medication for one or more weeks to temporar-ily halt your ovaries' normal functioning.This makes it easier to control your response to fertility drugs. A doctor or nurse will give you an injec-tion or instruct you about how to inject the medication daily at home.The risks: The medications can cause hot flashes, vaginal dryness, fatigue, sleep problems, body aches, mood swings, breast tenderness, headache, and/ or vision problems.
Stimulating egg production: In a normal menstrual cycle, one egg matures and, at ovulation, is re-leased from an egg-containing sac (called a follicle) on the ovary. In egg donation, the goal is to obtain
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several mature eggs. You will be prescribed medication to stimulate your ovaries to mature more eggs than normal (called "controlled hyperstimulation"). The medications are similar to the hormones that your body produces, but at much higher doses. These medications must be injected (either under your skin or into a muscle). Treatment will start on a specific day of your cycle and continue for about ten days. You will be shown how to inject the medications. If you are unable to inject yourself reliably, you will need someone else to do it for you.The risks: You may develop soreness, redness or mild bruising around the injection site. You may expe-rience mood swings, tender breasts, enlarged ovaries and mild fluid retention. Occasionally, the medi-cations cause more hyperstimulation than intended (known as "ovarian hyperstimulation syndrome," or OHSS). This will cause fluid retention and swelling of the ovaries. In mild OHSS, you may have ab-dominal pain, pressure and swelling. This should go away after your next period. In moderate OHSS, you may require careful monitoring, bed rest and pain medication. Severe OHSS is rare but can cause serious medical complications, including blood clots, kidney failure, fluid build-up in the lungs, and shock. In rare cases, hospitalization is necessary and the condition can be life-threatening. One or both of your ovaries may have to be removed. The risk of OHSS decreases after the eggs are retrieved.If you show signs of OHSS before the eggs are ready to be retrieved, the doctor may decide that it is too risky for you to keep taking the hormones. You must stop using the medication and the cycle will be canceled.If you decide, for some reason, not to undergo egg retrieval after having completed fertility drugs, you increase your risk of OHSS. Very rarely, an enlarged ovary will twist on its stalk and cut off its blood supply. This painful condition requires immediate surgery and the ovary may have to be removed. Also, very rarely, a woman has an allergic reaction to fertility drugs.You can become pregnant during the cycle, if you have unprotected intercourse. This could occur if some of the eggs are released before retrieval, or if the doctor is unable to retrieve all of the mature eggs. There is a chance that you could become pregnant with twins, triplets or quadruplets. You must abstain from intercourse or use effective barrier contraception. Ask the doctor about restrictions on in-tercourse during the donation cycle.The long-term risks of fertility drugs are unknown. A few studies suggest that fertility drugs might in-crease a woman's risk for developing ovarian cancer later in life. Others do not show this link. At this time, no one knows for sure.
Monitoring your progress: During the donation cycle, you must have frequent blood tests and ultra-sound examinations to track the developing eggs and to see how you are responding to the hormones. Based on these tests, you will be told how to adjust the dose of medication. The ultrasound exams in-volve inserting an ultrasound probe (about the size of a tampon applicator) into your vagina so the doc-tor can see the growing follicles on your ovaries.When the time is right, you will receive a final injection of another drug to prepare the eggs for re-trieval. This injection is given shortly before egg retrieval.The risks: Blood drawing can cause mild discomfort and there is a chance you will develop a bruise in the area where the needle was inserted. Ultrasound examination may be slightly uncomfortable but has no known risks.
Removing the eggs: The eggs will be removed from your ovaries in a minor surgical procedure called transvaginal ovarian aspiration. An ultrasound probe will be inserted into your vagina. A thin needle at-tached to the probe will be inserted into each follicle. Using suction, the egg and liquid inside each fol-licle are removed. You may be given painkillers, sedatives or anesthesia during the retrieval, which lasts about 30 minutes. When all the eggs have been retrieved, you will recover for a few hours before going home. You must have someone drive you home. Afterwards, you will need to rest for the day. Of-ten, it takes several days of restricted activity to recover.
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The risks: After the needle is inserted into the ovary, there may be bleeding. Although rare, it is possible to damage or puncture the bowel, bladder or nearby blood vessels. In the unlikely possibility of severe internal bleeding or serious damage to the pelvic organs, major abdominal surgery may be needed.To prevent infection, you may be given antibiotics. If infection occurs, it may affect your own future fertility. Ask the doctor about the risks of all medications used during retrieval.
Follow-up care: You should be given clear instructions about what to do if you need medical attention. In some programs, donors return for one or two check-ups. You may also be scheduled to meet with a counselor.Many women are concerned that giving up some of their eggs may reduce their ability to later become pregnant. If there are no complications, being an egg donor should not affect your later fertility. How-ever, if you develop serious complications, involving bleeding, infection, or loss of an ovary, it may jeopardize your ability to conceive.
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Criteria For Surrogates:
Have given birth to at least one healthy child with no complications Be between the ages of 20-38 years old, ages can vary with Intended Parents approval Healthy lifestyle and BMI not to exceed 32, no smoking or drug use No history of serious medical problems or complications during pregnancy No history of pre term deliveries before 36 weeks (unless multiples) Be willing and able to provide pregnancy/delivery records and current physical records Have transportation and a willingness to attend all doctor’s appointments Be willing to undergo evaluations and screenings, including STD and drug testing Must have stable home and income prior to Surrogacy Must be able and willing to receive/reply within 12 hours to emails, phone calls, text messages, and
to Intended Parents. May not be pregnant nor breast feeding and must have a regular cycle Must not have had the depo shot in the last 9 months
Fee Schedule: (May vary)
Surrogate Compensation California $35,000-$60,000 base rate The surrogate compensation will be paid in monthly installments once fetal heart beat is verified by the physician’s office.* A previous Surrogate may request higher compensations to be negotiated during the legal contract phase. Surrogate should notify agency in writing of prices requested so this can be noted on her profile. A Surrogate may also request a lower fee to match an Intended Parent’s request.Twin Compensation $8,000 In the case of a twin conception, the Surrogate will receive an additional fee compensation of $8,000 to be paid in installments once 20 weeks gestation is reached.Monthly Misc. Allowance $400 This allowance is to be used for such things as: telephone calls, faxes, postage, child care, house clean-ing fees, or any other additional costs to the Surrogate. An additional $200 will be added for organic eating.Maternity clothing Allowance $1,000 Once the Surrogate has reached 16 weeks gestation, she will receive a one-time disbursement of $1,000 for clothing.Gym Fee: $600Paid direct to the Surrogate’s gym of choice with proof of enrollment. Surrogate must request this op-tional fee.Medication Fee $1,000 This fee is a onetime disbursement for the initial medications required to begin the surrogacy process.Embryo Transfer Fee $2,000 Upon the physician’s office verification of embryo transfer, this onetime fee is disbursed to the Surro-gate. It is meant to cover bed rest, lost wages, and child care at the time of transfer.Invasive Procedures $1,000 Should the Surrogate require additional medical procedure, including but not limited to, amniocentesis, D&C, fetal reduction, hysteroscopy, or ectopic pregnancy, this fee will be disbursed.C-Section $5,000 The Surrogate will receive an additional $5,000 should a c-section be required for delivery.
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Lost Wages TBD In the event that the Surrogate is put on work restriction or bed rest, she will be compensated her lost wages minus disability payments for said wages. This will continue until 4-6 weeks post-delivery.Psychological Support $3,000 The Surrogate can request support if needed throughout the pregnancy and up to 8 weeks after birth.Health Insurance Should the Surrogate not have insurance coverage that includes maternity, the Intended Parents will be required to purchase a policy for the Surrogate.Travel Fees VaryTravel pertaining to surrogacy over 60 miles reimbursed at cost (.60 per mile driven, child care up to $160/24 hours, hotel, plane tickets, food allowance at $50/day, ect)Life Insurance The Intended Parents will provide the Surrogate a $250,000 one year life insurance policy at the Surro-gate’s request.Attorney Fees $1,000 – $3,500 The Surrogate has the right to legal representation throughout the contract building process at the ex-pense of the Intended Parents.House Keeping and Childcare required during bed rest will be in addition and will be outlined in your contract. These vary based on needs and do have limits that cannot be exceeded.
Process:
Apply on-line at CentralCoastSurrogacy.com or with our forms in this email Complete Surrogate Profile with a minimum of pictures. Please include a close up and full body
of yourself and some of your immediate family. Remember to make sure pictures are clear and show the best of you. This will increase your chances of matching.
Take Medical Record Request form to your OB to obtain your latest physical/pap smear results and your birth record (these may need to be obtained from the hospital as well)
Sign and return Surrogate Agreement Submit a copy of your and your spouse’s driver license and health insurance card Submit any transcripts, resume, or awards you would like to be considered Create a skype and wechat app account for parent meetings Begin matching process Psychological Screening Legal Contracting with Intended Parents IVF Clinic Clearance Begin medications as directed and schedule transfer
Insemination of Eggs and Embryo Culture
Following egg retrieval, the follicular fluid is immediately transferred to the adjacent laboratory for identification of eggs, evaluation, and preparation for insemination. In the process of collecting the fol-licular fluid, it is possible that a large number of eggs may be retrieved. It is strongly recommended that all of these eggs be inseminated to maximize the number of embryos available for subsequent transfer. Any objection(s) to this policy should be stated in writing and attached to the IVF-ET consent form with the understanding that pregnancy success may be reduced. Otherwise, the prepared sperm will be added to each egg and they will be allowed to incubate overnight under controlled laboratory condi-
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tions. The next day, each egg is evaluated for evidence of fertilization. However, it is possible that no eggs are fertilized. If this happens, the laboratory staff will re-inseminate the eggs or perform intracyto-plasmic sperm injection (ICSI) in hopes of obtaining embryos for transfer. If fertilization still does not occur, the eggs will be discarded and the remainder of the procedure will be cancelled. In the case of severe male factor, the couple may be asked to consider the option of using anonymous donor sperm (obtained through a licensed sperm bank for use as a "backup" or secondary sperm source) if it is not possible to obtain sufficient sperm from the partner at the time of fertilization.The eggs that have fertilized will be allowed to develop for two or more additional days under con-trolled laboratory conditions before they are placed inside the woman's uterus. Depending upon the couple's wishes, some fertilized eggs/ embryos may be frozen and stored for future use.After the embryos are transferred to the womb, the woman will continue progesterone supplementation that begins on the evening of your egg retrieval procedure. Progesterone can be taken as a combination of oral troches and rectal/vaginal suppositories or by injections. Administration of these medications af-ter egg collection has been shown to create a more favorable uterine environment for the embryos, which therefore increases pregnancy rates. Side effects of progesterone may include, but are not limited to the following:1st Vaginal dryness;2nd Bloating, breast tenderness;3rd Depression, mood swings;4th Delay of menses.Synthetic progesterone-like medications have been associated with certain birth defects. By using only natural progesterone, the risk of drug-induced birth defects is significantly reduced. It is important to note, however, that birth defects occur in approximately 3% of spontaneously-conceived pregnancies in the USA. Therefore, use of natural progesterone does not guarantee a child without a birth defect.
Transferring Embryos to the Uterus Embryos are transferred on either day three or day five of development. The embryologists at GRS are highly-skilled in identifying "healthy" embryos and in some cases will recommend that a patient extend embryo development to day five, known as the blastocyst stage. Blastocyst transfer has become quite common in IVF cycles as it can increase chances for success while decreasing the likelihood of multi-ples. Your physician will work closely with the embryologists to determine if a day three or day five transfer would be ideal for your cycle.Embryos are transferred to the uterus through a small tube (catheter). This procedure is much like a pap smear and does not require any anesthesia and is usually painless. The embryos are placed in a small amount of fluid inside the catheter, which is passed through the cervix at the time of a speculum exami-nation. The embryos are placed in a manner so they reach the top part of the uterus. The number of em-bryos transferred depends on individual circumstances of the couple, and this decision will be made collectively by you, your physicians and the embryologist. Typically, two to four embryos are be trans-ferred in one treatment cycle.Embryo transfer can cause mild cramping. Although unlikely, during the embryo transfer the embryo(s) may be displaced through the cervix (causing loss of embryos) or into the fallopian tubes (causing pos-sible tubal pregnancy). There is a small risk of bleeding or infection as a result of the transfer proce-dure.After transfer, the woman may get dressed and leave after a brief recovery period. A pregnancy test will be done twelve to fourteen days after the transfer, regardless of the occurrence of any uterine bleeding.The transfer of several embryos increases the probability of success. A multiple embryo transfer also increases the risk of a multiple pregnancy. Any multiple pregnancy carries an increased risk of miscar-riage(s), premature labor and premature birth as well as an increased financial and emotional cost. Pregnancy-induced high blood pressure and diabetes are more common in women pregnant with more
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than one fetus. Prolonged hospitalization may be necessary for these pregnant women and for the mother and babies after delivery. Tubal (ectopic) pregnancy is also possible, and a combination of nor-mal pregnancy and ectopic pregnancy may occur. A tubal pregnancy is a condition that may require la-paroscopy or major surgery for treatment. Like spontaneous (natural) conceptions, pregnancies that arise through IVF may result in miscarriage. In the event of a miscarriage, a dilatation and curettage (D&C) may be necessary.
Injections For Infertility
It's a painful fact of life that IVF (In Vitro Fertilization) treatment involves giving the woman lots of in-fertility medications through injection. While most people are naturally needle-phobic, learning how to take these injections yourself can help simplify your life considerably!
If you find the idea of giving yourself a shot more than you can stomach, then you can get your hus-band to give them to you. Trust me, no one will give them with more love and care (if he messes up, he will never hear the end of it !) - and this way he can learn a new skill as well.
There are basically 2 types of injections - intramuscular IM); and subcutaneous ( SC).
Lupron (Buserelin) is usually given subcutaneously; while Menogon ( HMG) is usually given intra-muscularly.
Please remember that there is very little risk of your harming yourself by giving yourself these injec-tions.It's a good idea to practise on an orange to increase your confidence levels. You could also request a nurse to supervise you the first time to give yourself a shot, so she can confirm you are doing a good job !
The steps are simple.
1. Assemble your equipment2. Load the medication into the syringe3. Prepare the injection site4. Give the medication5. Clean up
Find a clean, quiet and comfortable place where you will not be disturbed. Many women find their bathroom or kitchen to be a good spot. Clean a place on the countertop so that you can lay your sup-plies down. Wash your hands well and dry them thoroughly. Gather your supplies. This includes your medications, syringes, needles for mixing drugs (usually big-ger) and needles for injecting the drugs (usually smaller), alcohol swabs and sharps container. If you are injecting more than one drug (for example both Buserelin and Menogon ) you will want to separate the equipment for one drug from the equipment for the other.
INTRAMUSCULAR INJECTIONS
This is an injection that you give into a muscle. You first need to load the medication into the syringe. You can use a 1 ml or 2 ml syringe. This is usually a simple matter of dissolving the powder in the sup-plied solvent .
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Step 1 Step 2
Step 3 Step 4
Step 5 Step 6If your medication comes in rubber-stoppered ampoules, you first need to draw up the solvent into a syringe. You do this by sucking up the solvent into the syringe by piercing the rubber stopper with a 20 gauge needle. You then need to squirt this solvent into the ampoules which contains the medication ( the active powder) by piercing the rubber stopper with the same 20 gauge needle, and allow it to dis-solve completely. The powder will dissolve instantly and the solution will become clear. Repeat this un-til you have loaded the required dose into the syringe. Usually, one 1 ml of solvent can dissolve up to 6 vials of the powder. Keeping the solvent volume low will help to reduce the pain of the injection.
If the medication comes in glass vials, you will need to open the vials by breaking off the glass tops of the vials, and following the above procedure. Open all the vials at one time to make it easier for your-self.
Once the medication has been loaded into the syringe, remove the 20 G needle, and replace it with a fine 23 G needle.
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Lying down-or standing with your weight off of the side to be injected-locate the upper outer quadrant (or quarter) of your buttock. The injection is given here. The other option is to give it in the outer as-pect of your thigh, along the middle third.
Take a deep pinch between your thumb and forefinger and wipe with alcohol. Then let dry.
Place the needle into this pinch of tissue and muscle completely, leaving none of the needle exposed. This ensures you are taking the injection deep into the muscle.
Draw back on the plunger. If you are accidentally in a blood vessel ( incidentally, this is highly unlikely ! ) , blood will appear in the syringe. If so, pull the needle out, replace it with a new, sterile needle, and repeat the process.
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Slowly push the plunger all the way to inject the medication, and pull the needle straight out. The key to a comfortable injection is swift needle entry followed by slow injection of fluid. Therefore, slowly push the plunger down then quickly withdraw the needle.
Alternate between your left and right sides, each time you give yourself an injection. This will prevent the muscles from becoming sore
Apply pressure and massage the injection site gently for thirty seconds after you administer the shot.
Using ice cubes can help to relieve some of the discomfort. Some patients find numbing the skin with ice cubes prior to taking the injection is also helpful.
Never reuse needles and syringes.
Dispose of the syringe in a biohazard container such as a Sharps container-or in an unbreakable plastic container such as a laundry detergent bottle that you can seal.
SUBCUTANEOUS INJECTIONS
A subcutaneous injection is one that is given just under the skin.
You first need to load the medication into the syringe. You usually use a disposable 1 ml insulin syr-inge. This is usually a simple matter of piercing the rubber cap of the ampoule with a 20 G needle, and sucking the required volume of the medication into the syringe, upto the required mark.
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Once the medication has been loaded into the syringe, remove the 20 G needle, and replace it with a fine 25 G needle.
The primary site for a subcutaneous injection in your abdomen is 2 inches on either side of your navel, or belly button.
Wash your hands thoroughly and make sure that the surface you work on is clean.
Sterilize the injection area with an alcohol swab by cleaning about two inches of skin around the injec-tion site. Let it dry for at least one minute.
Remove the needle cover.
Pinch the area of skin you have cleansed with alcohol. The injection is given here.
Holding the needle like a pencil about 1 inch above the injection site, quickly insert the needle.
Release the fold of skin.
Depress the plunger all the way, injecting all of the medication, and pull the needle straight out.
Never reuse needles or syringes. Dispose of the syringe in a biohazard container such as a Sharps con-tainer-or in an unbreakable plastic container such as a laundry detergent bottle that you can see.
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Central Coast Surrogacy, LLCbuilding family together
Mail: PO Box 6659. Santa Maria. CA. 93456Office: 805-314-2918..... Fax: 805-980-4459
www.CentralCoastSurrogacy.com
Egg Donor/Central Coast Surrogacy, LLC Agreement
Please copy this form into a separate document and print. Initial the bottom of each page and sign and date the last page.
Central Coast Surrogacy, LLC (“CCS”) is an agency based in Santa Maria, CA, which assists indi-viduals and couples (“Intended Parents”) in locating and selecting a suitable Egg Donor and/or Surrogate for the purpose of creating a child(ren). CCS aides the Intended Parents, Egg Donor, and Surrogate in administration of agreements, assists in coordinating all necessary medical appointments with the physician(s), the mental health professional(s), attorney(s) and other necessary professionals. CCS fees for these services are paid for by the Intended Parents. While CCS is to provide assistance, guidance and support to the Surrogate, the Surrogate must realize
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that CCS also has commitments to the Intended Parents as well and must act in the best inter-est of all parties whenever possible.
The Egg Donor agrees to inform Central Coast Surrogacy, LLC of all significant changes in her personal life, including, but not limited to, separation/divorce, marriage, address and tele-phone changes, employment changes, insurance coverage changes, and health changes, as this may affect the Egg Donor’s contractual obligations with the Intended Parents.
The Egg Donor understands that the financial obligations arising from the donation process will be set forth in a contract between the Egg Donor and the Intended Parents and that the In-tended Parents, and not CCS will be responsible for such obligations.
The Egg Donor declares that all information provided to CCS in connection with the donation process is complete and accurate to the best of the Donor’s knowledge. The Egg Donor will in-form CCS as soon as possible if it is discovered that any information is inaccurate or incom-plete. The Egg Donor understands that as a part of the donor process CCS will need to share said information provided by the Egg Donor to mental health, medical, and legal professionals and to the insurance company and Intended Parents. The Egg Donor further understands that the information obtained from CCS questionnaires, previous records, mental health, medical, legal and insurance professionals regarding Egg Donor may be shared with appropriate parties including, but not limited to, CCS employees, Intended Parents, doctors, nurses, clinic coordi-nators, mental health professionals, insurance professionals, ect. The Egg Donor, by signing this document, authorizes Central Coast Surrogacy staff to access said records for the intent of egg donation and surrogacy and to release said information to such professionals as deemed ap-propriate for the donation and surrogacy process and releases CCS of any and all liability in connection with the gathering and releasing of all information current and future in connection with this or any future surrogacy arrangement. The Egg Donor agrees to sign any additional re-leases if necessary or required.
The Egg Donor acknowledges that CCS cannot represent or warrant the accuracy of complete-ness of any information provided to her by, or regarding the Intended Parents. The Egg Donor further acknowledges that CCS may not share with the Egg Donor information of a confidential nature (that is not necessary or relevant to the surrogacy process) that has been provided to CCS by the Intended Parents.
The Egg Donor understands that although CCS strongly recommends psychological screening or assessment of the Intended Parents, it is not required, and that the medical screening per-formed on the Intended Parents is determined by the medical professionals selected by the In-tended Parents, not CCS. The Egg Donor also realizes that if the Intended Parents are a couple, there is no guarantee that the couple may not separate or divorce during the donation process.
The Egg Donor understands that she is not an employee, agent or representative of CCS or the Intended Parent. The Egg Donor further understands that the tax responsibilities arising in con-nection with payments received in connection to the donor process is the responsibility of the
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Egg Donor to seek advice from a tax specialist if she has any tax questions or issues at her own expense.
The Egg Donor promises that she will conduct herself with maturity and sensitivity and under-stands that acting as an Egg Donor will require an extraordinary commitment and dedication. The Egg Donor agrees to use her best efforts to fulfill all of her obligations arising in connection with the donor process, including, but not limited to, making all necessary appointments, tak-ing all required medications as directed, and communicating all updates to CCS, and that failing to do so may arise in a breach of contractual obligations for which the Egg Donor, not CCS, may be liable.
The Egg Donor agrees to and understand that pictures sent to CCS are property of CCS and can be used on social media and sent to the Intended Parents unless otherwise told so by the Sur-rogate prior to posting/sending in writing. CCS is not responsible for any damages once shared by self, donor, or Intended Parents.
The Egg Donor understands that by signing this Agreement, she is agreeing to make herself available to serve as an egg Donor for Central Coast Surrogacy, LLC for a minimum of four months from the signing of this form. The Egg Donor understands that her questionnaire may be submitted to various Intended Parents, and if selected, the Egg Donor will be expected to commence an egg donor arrangement with that couple or person immediately once she agrees to said match. The Egg Donor understands and agrees that violation of these terms will constitute grounds of removal from CCS surrogacy program and can expose the Egg Donor to monetary damages for expenses incurred on behalf of CCS and the Intended Parents in con-nections with her matching and application process.
By signing this Agreement, the Egg Donor agrees to the terms and conditions set forth above and is representing she has read the warranties and representations herein, and is signing this Agreement knowingly, willingly, and voluntarily.
AGREED TO AND ACCEPTED BY:
____________________ ____________
Egg Donor’s Name (Print) Date
____________________
Egg Donor’s Signature
* This must be printed. The bottom of each page must be initaled and the bottom of the last page
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signed. This Agreement can be scanned and emailed back, faxed in, or mailed to the PO Box above.
Central Coast Surrogacy, LLCbuilding family together
Mail: PO Box 6659 . Santa Maria . CA . 93456Office: 805-314-2918..... Fax: 805-980-4459
www.CentralCoastSurrogacy.com
Surrogate/Central Coast Surrogacy, LLC Agreement
Please copy and paste this into a separate document and print. Initial the bottom of each page and sign and date the last page.
Central Coast Surrogacy, LLC (“CCS”) is an agency based in Santa Maria, CA, which assists indi-viduals and couples (“Intended Parents”) in locating and selecting a suitable Egg Donor and/or Surrogate for the purpose of creating a child(ren). CCS aides the Intended Parents, Egg Donor, and Surrogate in administration of agreements, assists in coordinating all necessary medical appointments with the physician(s), the mental health professional(s), attorney(s) and other necessary professionals. CCS fees for these services are paid for by the Intended Parents. While
23
CCS is to provide assistance, guidance and support to the Surrogate, the Surrogate must realize that CCS also has commitments to the Intended Parents as well and must act in the best inter-est of all parties whenever possible.
The Surrogate agrees to inform Central Coast Surrogacy, LLC of all significant changes in her personal life, including, but not limited to, separation/divorce, marriage, address and tele-phone changes, employment changes, insurance coverage changes, and health changes, as this may affect the Surrogate’s contractual obligations with the Intended Parents.
The Surrogate understands that the financial obligations arising from the surrogacy process will be set forth in a contract between the Surrogate and the Intended Parents and that the In-tended Parents, and not CCS will be responsible for such obligations.
The Surrogate declares that all information provided to CCS in connection with the surrogacy process is complete and accurate to the best of the Surrogate’s knowledge. The Surrogate will inform CCS as soon as possible if it is discovered that any information is inaccurate or incom-plete. The Surrogate understands that as a part of the surrogacy process CCS will need to share said information provided by the Surrogate to mental health, medical, and legal professionals and to the insurance company and Intended Parents. The Surrogate further understands that the information obtained from CCS questionnaires, previous records, mental health, medical, legal and insurance professionals regarding the Surrogate may be shared with appropriate par-ties including, but not limited to, CCS employees, Intended Parents, doctors, nurses, clinic coor-dinators, mental health professionals, insurance professionals, ect. The Surrogate, by signing this document, authorizes Central Coast Surrogacy staff to access said records for the intent of surrogacy and to release said information to such professionals as deemed appropriate for the surrogacy process and releases CCS of any and all liability in connection with the gathering and releasing of all information current and future in connection with this or any future surrogacy arrangement. The Surrogate agrees to sign any additional releases if necessary or required.
The Surrogate acknowledges that CCS cannot represent or warrant the accuracy of complete-ness of any information provided to her by, or regarding the Intended Parents. The Surrogate further acknowledges that CCS may not share with the Surrogate information of a confidential nature (that is not necessary or relevant to the surrogacy process) that has been provided to CCS by the Intended Parents.
The Surrogate understands that although CCS strongly recommends psychological screening or assessment of the Intended Parents, it is not required, and that the medical screening per-formed on the Intended Parents is determined by the medical professionals selected by the In-tended Parents, not CCS. The Surrogate also realizes that if the Intended Parents are a couple, there is no guarantee that the couple may not separate or divorce during the surrogacy process.
The Surrogate understands that she is not an employee, agent or representative of CCS or the Intended Parent. The Surrogate further understands that the tax responsibilities arising in con-nection with payments received in connection to the surrogacy process is the responsibility of
24
the Surrogate to seek advice from a tax specialist if she has any tax questions or issues at her own expense.
The Surrogate promises that she will conduct herself with maturity and sensitivity and under-stands that acting as a Surrogate will require an extraordinary commitment and dedication. The Surrogate agrees to use her best efforts to fulfill all of her obligations arising in connection with the surrogacy process, including, but not limited to, making all necessary appointments, taking all required medications as directed, and communicating all updates to CCS, and that failing to do so may arise in a breach of contractual obligations for which the Surrogate, not CCS, may be liable.
The Surrogate agrees to and understand that pictures sent to CCS are property of CCS and can be used on social media and sent to the Intended Parents unless otherwise told so by the Sur-rogate prior to posting/sending in writing. CCS is not responsible for any damages once shared by self, surrogate, or parents.
The Surrogate understands that by signing this Agreement, she is agreeing to make herself available to serve as a Surrogate for Central Coast Surrogacy, LLC for a minimum of four months from the signing of this form. The Surrogate understands that her questionnaire may be sub-mitted to various Intended Parents, and if selected, the Surrogate will be expected to com-mence a surrogacy arrangement with that couple or person immediately once she agrees to said match. The Surrogate understands and agrees that violation of these terms will constitute grounds of removal from CCS surrogacy program and can expose the Surrogate to monetary damages for expenses incurred on behalf of CCS and the Intended Parents in connections with her matching and application process.
By signing this Agreement, the Surrogate agrees to the terms and conditions set forth above and is representing she has read the warranties and representations herein, and is signing this Agreement knowingly, willingly, and voluntarily.
AGREED TO AND ACCEPTED BY:
____________________ ____________
Surrogate’s Name (Print) Date
____________________
Surrogate’s Signature
* This must be printed. The bottom of each page must be initaled and the bottom of the last page signed. This Agreement can be scanned and emailed back, faxed in, or mailed to the PO Box above.
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AUTHORIZATION TO RELEASE MEDICAL INFORMATION
I authorize the named health care provider to release the information or records specified to Central Coast Surrogacy, LLC fax 805 980 4459, phone 805 314-2918 upon request in person or by mail to the address specified at the time of the request. PO Box 6659 Santa Maria CA 93456.Provider: (name and address)
Patient: SS#: DOB: Child:DOB:Child:DOB:
RECORDS AUTHORIZED TO BE RELEASED:
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Admission history and physicalDischarge summary
Lab reportsRadiological images
Records relating to drug or alcohol abuse (must specify the extent or nature of the records to be released)Medication administration logs, dietary logs, staff contact or service logs, and other records that may not be part of my individual medical record, but which contain information relating to me(These records should be redacted to protect information pertaining to other patients.)Other (specify):release all records/physical/lab to qualify for egg donation/surrogacy. Include pregnancy logs, birth logs, newborn screening, and last pap smear and physical results.
Extent or nature of records to be released: (example, specific hospitalization or visit)
All pregnancy related and annual physical/lab work
This information will be used for the purpose of :Investigating an allegation of abuseProviding advocacy servicesOther activities at the request of the individ-
ual
Verifying my eligibility for services offered by the
Legal representation
I understand that:1. I may refuse to sign this authorization and that it is strictly voluntary.2. My treatment, payment, enrolment or eligibility for benefits may not be conditioned on signing this authorization.3. I may revoke this authorization at any time in writing, but if I do, it will not have any affect on actions taken prior
to receiving revocation. Further details may be provided in the Notice of Privacy Policy4. If the requestor or receiver is not a health plan or healthcare provider, the released information may no longer be
protected by privacy regulations and may be re-disclosed.5. I understand that I may see and obtain a copy of the information described on this form, for reasonable copy fee
if I ask for it.6. I get a copy of this form after I sign it.7. This includes confidential lab results, such as HIV results.
I have read the above and authorize the disclosure of the protected health information as stated,
______________________________________ _________________________Name/Signature Date
___________________________________Driver License Number
Instructions for Authorization to Release Medical Information
Please use one for each OBGYN used for pregnancy and your last physical and pap smear as well as one for each delivering hospital. Please inform your case manager of the approx. dates you saw each.
Instructions
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You can fill this form in on the computer for printing. When filling in the form on the computer, you can move between fields by
using the TAB key, the ARROW KEYS, or the mouse. The SPACE BAR or a MOUSE CLICK will check or uncheck boxes.
If you fill in too much text in a blank, the text block may be extended and the signature block may be forced onto a second page. This is okay, and this is also why the second page of this document is blank.
You can print the form for signing after filling in the blanks. You do not need to save a copy to your computer.
To simplify completing a copy of the form for many different providers, you may save a partially completed copy of the form on you computer and change only the provider or other information necessary for each additional copy before printing.
Explanation of HIPAAThe Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires an Authorization to Release Medical Information in order for health care providers to release medical information or records. New requirements for authorizations became effective April 16, 2003. This requirement also extends to organizations related to health care providers, such as insurance companies and other organiza-tions closely associated with health care providers, and their contractors. It is necessary to use this form when requesting information from health care providers because this law requires specific information to be provided on an au-thorization. This form should not be used to request records not covered by HIPAA (records obtained from a source other than a health care provider).
Medical providers are mandated to protect information and to require the use of forms that comply with the law. This form complies with the requirements of HIPAA and should be accepted by all medical providers. However, if a medical provider insists that the provider’s form be used, you may want to use that form if it will expedite the process of obtaining records. Please notify the AWPPW if this situation arises so that the problem can be resolved.
Requirements for using the form:HIPAA also requires specific steps in obtaining and utilizing an authorization to re-lease medical information. Therefore, it will be necessary that you:
Utilize one form for each medical provider from whom records are re-quested.
Complete the forms in their entirety before asking a client to sign the form. Date the form at the time it is signed. Provide a copy of each completed form to the client.
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Advice for using the form:In addition, in order for you to make the best use of this form, you should:
1. Make a written request for copies of records, if possible.2. Specify the exact records you are requesting in a cover letter. You
may want to have a client check items to release that you do not need at the time. For example, you may have the client check an item such as ‘Medication administration logs…’ which may or may not be relevant to an investigation. You could then request those records at a later time if neces-sary.
3. Specify the period of time for which you are requesting records.4. Clearly specify the location to which the records should be mailed or
another method of delivery.5. It may be helpful to call some medical providers in advance to obtain an es-
timate of the cost involved and the provider’s procedure for billing.
Note on records authorized to be releasedAll types of notes that you may need to request at any time from a particular provider should be checked. Otherwise, you may need to have another authoriza-tion signed before requesting additional records. There may be additional issues with some particular types of records:
Records related to HIV status may not be released unless the individual has signed a separate release specific to HIV related information. 5 U.S.C. §19203-D.
Psychotherapy notes may not be released unless the individual has signed a separate release specifying that such notes may be released. 45 CFR §164.508(b)(3)(ii).
You must specify on the authorization the extent or nature of records to be released for drug or alcohol records. 42 U.S.C. 290dd-3; 42 U.S.C. 290ee-3; 42 C.F.R., Part 2. The individual may also use this section to limit other records to be released.
‘Medication administration logs…’ relates to information that is not a part of an individual’s medical record. Such information may be particularly useful in abuse/ neglect investigations but must be specifically requested and have other patients’ information redacted. This is time-consuming and costly, and such records should only be requested if necessary to investigate the specific allegations or a serious incident.
Note on statement of purpose
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The statement of purpose should reflect the reason for the request. The client may elect to check the last statement ‘other activities at the request of the indi-vidual’ if desired.
Note on patient representativesIf a patient’s representative is signing the authorization, you must specify the rela-tionship of the representative to the patient. Common relationships include:
Parent or Guardian Conservator (a copy of the order appointing the conservator should also be
provided) Attorney-in-fact (a copy of the notarized Power of Attorney should also be
provided)
Central Coast Surrogacy, LLCBuilding family together
APPLICATION This information will be used for clearances and contracting. Please, prior to applying, refer to the qualifications listed in your Surrogate/Egg Donor handbook, pinned to our facebook page, and avail-able on-line.
Email To: your case manager if assigned or [email protected] To: PO Box 6659, Santa Maria, CA 93456
1. Full Name: 2. Date of Birth:3. Driver License Number: 4. Social Security Number: 5. EMAIL Address: 6. Phone Number: 7. Full Address: 8. Mailing Address:9. Skype Address:10. Wechat Address:11.Are you a US citizen? 12.Weight: 13.Height: 14.BMI (calculator available online):15.Do you smoke or use Tobacco of any form?16. Have you ever used an illegal drug?
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17.Have you ever given birth before?18.How many prior c-sections?19.What is your blood type?20.Current OB (Name, Address, Phone, Fax)?21.Local Hospital with Maternity (Name, Address, Phone, Fax)?22.Current Pharmacy (Name, Address, Phone, fax)?23.Are you currently single, married, separated, divorced, or widowed? 24.Spouses Name:25.Spouses/Partners Date of Birth:26.Spouses/Partners Driver License Number:27.Spouses Phone Number:28.Spouses email address:29.Emergency Contact name, phone number, and email address:30.Have you or your partner ever been convicted of a felony? 31.Have you ever had gastric bypass surgery? 32.Have you ever been diagnosed with diabetes? 33.Have you ever been diagnosed with syphilis? 34.Have you ever been diagnosed with toxemia? 35.Have you ever been diagnosed with hypertension? 36.How did you hear about our program?
*Please remember when submitting your application and profile, to include a copy of your and your live in partner/spouse’s driver license for your background check as well as the front and back of ANY health insurance card.
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Central Coast Surrogacy, LLCbuilding family together
First NameEgg Donor/Surrogate/Both
(Insert Profile Pictures Here)
Base Fee for Single:Base Fee for Twin:
Status: AvailableRepeat Donor or Surrogate:Insurance Company:City, State, Country: Are you willing to travel out of state for up to 5 days?Are you willing to travel out of country for 7-10 days?Occupation: Description of duties, days and hours worked:Are you legally married?Husband/Partner's Occupation: Description of job duties, days and hours worked:Husband/Partners DOB:Your Date of Birth: Your Height:Your Weight:BMI:Blood Type:Natural Eye Color: Natural Hair Color: Hair Type: Body Type: Complexion:Ethnicity: Race/National Origin: If two or more racial groups, please describe:Children: Child 1 Age & Sex: Child 2 Age & Sex: Child 3 Age & Sex: Child 4 Age & Sex: Child 5 Age & Sex: Parent's Ancestry: (please be as specific as possible; e.g., French, English)Father's mother: Father's father:Mother's mother: Mother's father:Religion at Birth: Practicing? Have you received any tattoos in the last year:Number of tattoos and date of last tattoo: Have you received any piercings in the last year: Number of piercings and date of last piercing:
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Other distinguishing features: Marital Status: Date of Marriage: Number of Divorces: Date(s) of Divorce(s): Have you or your husband/partner ever:Filed for bankruptcy?Please Explain: Been in a psychiatric facility? Please Explain:Been arrested? Please Explain:Been involved in any legal cases, or any that are pending? Please Explain: Been in a substance abuse program? Please Explain:Do you own a car? Do you drive? Do you have a valid driver's license?
Medical / Genetic Information:
Were you adopted? Do you have information about your biological parents? Blood Type: Sexual Orientation: Number of Pregnancies: Number of Miscarriages (please include date of miscarriage, how many weeks gestation and reason if known):Number of Abortions (please include daye of abortion, how many weeks gestation, reason for abortion):Pregnancy #1:Date of Birth:Months trying to conceive: Birth Weight: C-section or Vaginal:Weeks Gestation At Delivery:Induced or Spontaneous Labor:Please select any complications that occurred:Pregnancy #2:Date of Birth: Months trying to conceive: Birth Weight: C-section or Vaginal:Weeks Gestation At Delivery:Induced or Spontaneous Labor:Please select any complications that occurred:Pregnancy #3:Date of Birth: Months trying to conceive: Birth Weight: C-section or Vaginal:Weeks Gestation At Delivery:Induced or Spontaneous Labor:Please select any complications that occurred: Pregnancy #4:Date of Birth: Months trying to conceive:Birth Weight:C-section or Vaginal:Weeks Gestation At Delivery:Induced or Spontaneous Labor:Please select any complications that occurred: Pregnancy #5:Date of Birth:Months trying to conceive:
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Birth Weight:C-section or Vaginal:Weeks Gestation At Delivery:Induced or Spontaneous Labor:Please select any complications that occurred:Tell us about any pregnancy complications(i.e. premature birth, bed rest, gestational diabetes,placenta previa, etc.)Surrogates and Egg Donors must have had a physical within the past 12 months to include a pap smear, CBC, thyroid, and STD lab.Date of last OBGYN visit: (mm/dd/yy) Date of last Pap Smear: (mm/dd/yy) Results: Good/NegativeHas your weight changed dramatically in the last five years for reasons other than pregnancy?Please explain why:Are you using birth control? What Method? For how long? Any complications experienced with this method? Do you smoke? How much per day? (in packs)Do you drink alcoholic beverages? How Often? (per day/week, etc) Have you ever used illicit drugs? Are you currently using illicit drugs? Do you have regular monthly menstrual cycles? Please provide details: Has anyone in your family had difficulty achieving pregnancy? Please explain:Are there twins or triplets in your family? Please explain:Have you or any of your partners ever had a blood transfusion? Please explain:Have you or your partner ever had any psychological counseling (including marriage counseling)?Please explain:Hospitalized for psychiatric illness? Please explain:Are you currently sexually active with anyone other than your partner listed on this application?Please explain:Have you ever been physically abused Yes/No:By whom?:Have you ever been sexually abused Yes/No:By whom?:Have you ever had thoughts or attempted suicide? If yes, have you had professional counseling? Do you suffer from Bipolar Disorder? If yes, have you had professional counseling? Do you suffer from any Anxiety Issues? If yes, have you had professional counseling? Have you ever been sexually assaulted? If yes, have you had professional counseling? Have you or your husband or partner or any past sexual partners ever been diagnosed with HIV or AIDS?Please describe any medical problems you may have/had: Please list any medications and dosage you are currently taking: Please list all other prescription medication and dosage taken over the last year and reason for taking: Please list any hospitalizations, surgeries, or plastic surgeries you have had and the dates each event oc-curred:Have you or your husband or partner or any past sexual partners ever been diagnosed with the following:Chlamydia - Syphilis - Gonorrhea - HPV - Genital Herpes - Hepatitis B - Hepatitis C -
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Ovarian Cyst - PID –
If any of your biological relatives have suffered from the following, please list their relation to you:
Down's syndrome:Mental retardation:Seizure disorder/Epilepsy:Muscular Dystrophy:Deafness or hearing problems:Blindness or Color Blindness:Corrective Lenses/Glasses: Glaucoma:Nearsighted or Farsighted: Schizophrenia:Suffers from depression:Serious birth defect:Heart Problems:More than 2 miscarriages:Skin discoloration/spots/rashes:Cancer - what type: Severe bleeding tendency (hemophilia):Stroke: Ulcer:Ovarian cysts:Uterine Fibroid:Asthma:Hyperactivity:Alcoholism:Drug Addiction:Learning Disability:Diabetes prior to age 55:
Biological family information:
Age Hair/Eye Color Height/Weight Occupation Health Status:Mother: Father: Maternal Grandmother: Maternal Grandfather: Paternal Grandmother: Paternal Grandfather: Sibling: Sibling:Child(ren) details, if applicable:Child Name Age Eye Color Hair Color Health Education / Employment Resume:
Position Duties Term:
What were your best subjects in school?
Please indicate which applies to you: Name and Date Graduated:
High School Graduate (please note surrogates must have a GED or be a high school graduate):
University/Years Completed/Degree Pursuing/Major:
Occupational School/College:
Associate Degree: Bachelor Degree:
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Masters DegreePh.D. or M.D. Degree:Other Doctoral Program:Other Education: SAT Score: ACT Score:GPA in College:Do you have plans on furthering your education? Please give details:
What are your goals in life?
Traits / Characteristics:
Please describe your personality and character:
What are your hobbies, interests and talents?
Do you play a musical instrument? Which one(s): Do you have any particular athletic abilities? Please Explain: What do you like to do in your spare time?
What is your philosophy on life?
Why do you want to be a Surrogate?
Briefly explain your understanding about how the Surrogate program works?
What do you plan to tell your children about you being a Surrogate?
What qualities would you consider most important in choosing a Recipient Couple?
What relationship do you want with the Intended Parents during conception and pregnancy?
Please indicate who you are NOT willing to work with:
Which type of surrogacy are you interested in?Gestational -Traditional - Have you ever placed a child for adoption? What kind of support do you expect from the following people:Your husband/partner?
Your parents?
Friends/co-workers?
What contact would you like during the process with the Recipient Couple, if any?
What kind of relationship do you want to have with your couple after the birth, if any?
How would you respond if the child wanted to see you at some time later in his or her life?
What message would you like to pass on to the Recipient Couple?
Would you like to meet the Recipient Couple?
Please explain your answer:
What is the maximum number of embryos you are willing to have transferred to you?
Are you willing to carry twins?
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Triplets? If so, please explain?
Would you undergo a selective reduction procedure if a multiple pregnancy is confirmed?
Do you have any objections to undergoing an amniocentesis if the Intended Parents request one?
If there is a medical problem with the pregnancy, or with the child you are carrying as a surrogate and the In-tendedParents want to consider abortion, would you allow them to make that decision based on the advice of their physician and personal beliefs?
Please explain:
Do you and your partner understand that, unless you have had a tubal ligation or your partner has had a va-sectomy,you must agree to abstain from sexual activity while undergoing medical treatment and participating in thisprogram?
Please complete the following sentences:
As an adult my favorite _________ is/are:Food:Color: Season: Holiday:Sport(s): School Subject:Book: Song: TV Program: Singer/Group: Movies: Hobbies:Do You: (Provide as much detail as you want)Sleep with stuffed animals? Believe there is life on other planets? Read the newspaper? Have gay or lesbian friends? Believe in miracles?Believe in fate? Believe it is possible to remain faithful forever?Consider yourself tolerant of others? Consider police a friend or foe? Like the taste of alcohol? Follow the news?Believe in astrology? Believe in magic? Pray? Have any pets?Sing in the shower?Consider yourself a hopeless romantic? Wish on stars? Like your handwriting? Believe in ghosts?Trust others easily? Consider yourself a liberal, conservative or moderate? Like sarcasm? Believe in the afterlife? What I value most:I am proud of:I feel strongly about:I believe that:I dislike:My immediate goals are:
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My future plans are:In ten years I want to be:What is your most memorable childhood experience?What is the funniest thing that ever happened to you?I regret that I did not:
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Next Steps:
You have completed the first step! Contacting Central Coast Surrogacy, LLC and receiving our in-formation packet! Now if you are ready to move forward here is what must be completed in full....
Agency contract must be read and signed by Egg Donors and Surrogates.
All Medical Records must be requested and received.
Profiles must be filled out completely with pictures that show you and your family in your best light.
Agency must receive a copy of your driver’s license and insurance card.
Some Surrogates are required, all urged, to receive a hep b vaccination.
Matching can occur quickly, but it may take several months.
Once matched, we will continue screening and IVF clinic appointment.
Attorney will be assigned and contracts will be written.
Surrogate is cleared to start medications and transfer.
Contact Information:
Central Coast Surrogacy, LLC
PO box 6659
Santa Maria, CA 93456
805-314-2918 phone
805-980-4459 fax
Founder: Danielle Hernandez
Wechat:momdanielle
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