Prenatal Information - Surrogacy Date MM DD YYYY Surrogates Name * First Name Last Name Partner/Support Person's Name First Name Last Name Primary Contact Number (###) ### #### Alternative Phone Number(s) Address Email Address Intended Parents Names Intended Parents Contact Information EDD Doctor/Midwife Name Number of Previous Pregnancies/Births Is there anything you would like us to know about your previous births? Do you currently have any health concerns? Other Practitioners Offering Support Caffeine/Alcohol/Tobacco/Drug Use Reason for Wanting a Doula Greatest Fear Regarding Pregnancy/Birth/Postpartum Who will be Present at the Birth Infant Plans Is there anything else you would like us to know regarding your surrogacy journey? Thank you!
