Surrogate Application Form

Please complete the following information as accurately as possible. All information is confidential and used solely to support your surrogacy journey.

Preferred Method of Contact

Weight (indicate kg or lbs)

State / Province / Territory

Education & Employment

Highest Level of Education Completed:

Languages Spoken Fluently:

Do you currently receive any government benefits (e.g., EI, disability, child tax, etc.)?

Yes

If yes, please specify government benefits received

CORRESPONDANCE

Some description about this section

Can we leave messages related to surrogacy on your voicemail?

Yes

Can we send you mail labeled with surrogacy-related return addresses?

Yes

BACKGROUND

Questions about your personal background (history, relationship and family)

Are you willing to submit a criminal background check?

Yes

Partner First Name

Partner Last Name

Partner's Occupation

Length of Relationship (Number of Years)

Do you currently use contraception?

Yes

Are you religious?

Yes

Do you have children?

Yes

If yes, please list name, age, gender

Lifestyle & Interests

List any and all hobbies, interests and recreational activities

Reason(s) for pursuing surrogacy:

How many children have you given birth to?

Please list your child(ren)’s first name(s), sex, and current age(s):

For each pregnancy, please list gestational age at delivery, birth weight, and delivery method (vaginal or C-section):

Are you currently pregnant or breastfeeding?

Yes

If yes, please explain

Have you experienced any pregnancy-related or postpartum complications (e.g., preeclampsia, hyperemesis, migraines, postpartum depression)?

Yes

If yes, please describe

Medical & Mental Health History

Have you ever been diagnosed with a mental health condition (e.g., anxiety, depression, postpartum depression)?

Yes

If yes, please specify

Have you ever experienced suicidal thoughts or attempts?

Yes

If yes, please explain

Do you have any current or past medical conditions?

Yes

If yes, please list all current or past medical conditions.

Are you currently taking any medications?

Yes

If yes, please list medications

Have you ever been treated for a sexually transmitted infection?

Yes

Other

If yes, please specify and include approximate date

Do you have a regular monthly menstrual cycle?

Yes

Fertility & Reproductive History

Have you ever been a surrogate?

Yes

If yes, please provide details

Have you ever donated eggs?

Yes

Have you undergone fertility treatments (e.g., IVF, IUI)?

Yes

If yes, please specify type of treatment and circumstances

Have you ever had any of the following procedures or experiences?

Surrogacy Preferences & Considerations

Which type of surrogacy are you interested in?

Would you be willing to carry twins?

Yes

Would you be willing to undergo selective reduction in the case of high-order multiples?

Yes

Would you consent to amniocentesis or other prenatal diagnostic testing if requested?

Yes

Intended Parent Preferences & Expectations

What level of contact would you prefer with the intended parent(s) before, during, and after pregnancy?

Would you allow intended parent(s) to attend medical appointments and be present at the birth?

Yes

Case-dependent

If case dependent, please explain

If requested, would you be willing to pump, freeze, and ship breast milk after delivery?

Yes

Matching Preferences

Are there any intended parent profiles you would not be willing to work with? (Check all that apply)

Do you have a preference for the type of intended parent(s) you would like to match with?

Do you have any specific matching criteria or boundaries? (e.g., termination preferences, midwife care, colostrum provision, social media sharing)

Do you smoke or have exposure to secondhand smoke?

Yes

If yes, please specify amount and frequency

Do you consume alcohol?

Yes

If yes, please specify amount and frequency

Do you or your partner use recreational drugs?

Yes

If yes, please specify the drug name, amount and frequency

Acknowledgement and Consent

By choosing to submit this questionnaire, I understand that True Match Surrogacy Ltd cannot guarantee a match with hopeful parents and only provides introductions, guidance, support and referrals throughout the process.

I consent to have this website store my submitted information so they can respond to my inquiry

I have read and agree to the Terms and Conditions and Privacy Policy

Can you spare a few minutes to do a quick survey? Your feedback will help us improve this website.

Yes

Which best describes you?

Intended parent

Potential surrogate

Egg / embryo donor

Fertility, legal, medical, or counselling professional

Friend or family member

Researching surrogacy

Other

What brought you to our website today?

I am looking for a surrogate

I am curious about becoming a surrogate

I want to understand Canadian surrogacy laws

I want to review fees and costs

I want to book a free consultation

I am comparing agencies

I followed a social media, Google, or referral link

Other

How did you find us?

Search engine (Google, Bing, or Yahoo)

Google Reviews

Google Maps

Google Business Profile

Trust Pilot Company Profile

Better Business Bureau

Chamber of Commerce

Facebook post

Instagram post

Advertising (Google)

Advertising (Reddit)

Advertising (Facebook)

Referral from friend or family

Referral from fertility clinic

Referral from lawyer or professional

Eventbrite webinar

Community Group (Reddit)

Community Group (Facebook)

News article or blog

Other

Were you able to find what you were looking for?

Yes

Somewhat

I was just browsing

What information was most helpful?

What information was missing, unclear, or difficult to find?

The website feels professional and trustworthy.

The information is clear and easy to understand.

The surrogacy process is explained well.

Fees and payment information are easy to find.

The website feels respectful and compassionate.

I felt encouraged to take the next step.

What almost stopped you from contacting us?

Cost

Trust or credibility concerns

Legal uncertainty

Privacy concerns

Not enough information

I am not ready yet

I could not find the right form or next step

Nothing

Other

What action are you most likely to take next?

Book a free consultation

Complete an intended parent questionnaire

Complete a surrogate screening questionnaire

Contact another agency first

Not sure yet

How likely are you to recommend our website to someone else? (0 = unlikely, 10 = absolutely)

Do you have any final comments or suggestions?

May we follow up with you?

Yes

Age Group (Years)

Under 18

18 - 30

31 - 40

41 - 50

51 - 60

Over 60

Country of Residence