Surrogacy Client Registration

Confidential and for official use only. Review our services and programme plans, then complete the form below.

1. Personal Information

Full Name *

Date of Birth *

Gender

Nationality

Marital Status

Occupation Address *

City

State / Province

Country

Phone Number *

Email Address *

Preferred Mode of Contact

2. Partner Information (if applicable)

Partner Full Name

Partner Date of Birth

Partner Gender

Partner Nationality

Partner Occupation

Partner Phone

Partner Email

3. Medical Information

Primary Physician

Contact Number

Fertility Specialist

Contact Number

Do You or Your Partner Have Any Medical Conditions That May Affect the Surrogacy Journey? If Yes, Please Provide Details Have You Undergone Fertility Treatments Before? If Yes, Please Provide Details (type of treatment, dates)

4. Programme Goals and Preferences

Preferred Programme Preferred Surrogate Accommodation

Full live-out means a separate Newlife-acquired and supervised apartment after 12 weeks, not the surrogate's personal residence. Partial live-in covers embryo transfer to 12 weeks and approximately 30 weeks to delivery, with supervised live-out arrangements between these stages.

Review programme inclusions and additional services. Newlife coordinates treatment through independent qualified clinics and hospitals. The Surrogacy-Only Plan excludes IVF, antenatal care, delivery and hospital medical fees.

Additional Services Requested Why Are You Considering Surrogacy? * Using Your Own Eggs? Using Your Own Sperm? Using Donor Eggs? Using Donor Sperm? PGT-A? Have You Identified a Surrogate? Would You Like Assistance Finding a Surrogate? Gender Preference (if applicable)

5. Legal Information

Have You Consulted a Lawyer About Surrogacy Agreements? Do You Have an Existing Surrogacy Contract? If Yes, Please Provide Details

6. Emergency Contact

Name

Relationship to Client

Phone Number

Email Address

7. Consent and Acknowledgement

Confidential and for official use only. Submit this information for Newlife's programme review. Clinical procedures, programme terms and any legal agreements will be discussed separately with the appropriate professionals.

Client Full Name as Acknowledgement * Date * Partner Full Name as Acknowledgement (if applicable) Partner Acknowledgement Date I acknowledge that the information provided is accurate to the best of my knowledge and consent to Newlife Conceptual using it to review my registration and contact me about the surrogacy programme. * Partner consent (if applicable).