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Intended Parents Application
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Intended Parents Application
Intended Parent's Name 名字
*
First
Last
DOB 生日 (MM/DD/YYYY)
*
Intended Parent's Name 名字
First
Last
DOB 生日 (MM/DD/YYYY)
Marital Status 婚姻狀態
*
Single 單身
Committed Relationship 穩定關係
Married 結婚
Divorced 離婚
Widowed 喪偶
Mailing Address 地址
*
Cell Phone Number 手機號碼
*
Email 電子郵箱
*
WeChat ID 微信帳號
Best Way to Contact 最好的聯絡方式
*
Phone 電話
Text 短訊
Email 郵件
WeChat 微信
Which program are you interested and wish to inquire more information 您需要哪項服務
*
Egg donor 捐卵
Surrogate 代孕
Concierge 協調/管理
How long have you been trying to get pregnant 您嘗試懷孕多久?
*
Are you currently working with a fertility clinic 您目前有合作的醫生與診所嗎?
*
Yes 有
No 沒有
Have not decided 尚未確定
Name of Physician 醫生名字
Name of Fertility Clinic 診所名字
Emergency Contact (Other than your partner) 緊急聯絡人 (非伴侶)
*
Relationship to you 與您的關係
*
Phone Number 電話號碼
*
Email 電子郵箱
When was your last menstrual period 您上次月經何時?
*
Do you have regular period 您的經期是否正常?
*
Yes 是
No 否
What type of birth control are you using 您使用何種避孕方式?
*
Have you ever had 您是否曾經有:
*
Premature delivery 早產
Miscarriages 流產
Abortion 墮胎
None of the above 以上皆無
How did you hear about us 您從何處得知我們?
*
Electronic Signature 電子簽名
*
Please enter your first and last name in this field. 請輸入您的名字.
Name
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