The best way to match you with the right surrogate is to get to know you first, kindly provide complete and accurate information to all the questions below. Thank you!

Contact and Personal Information


Intended Parents #1 Contact Details for International Clients

Primary Country of Residence:

Intended Parent #2 (if applicable):

Intended Parent #2 Contact Detail for International Clients

Surrogate Criteria Information (represents the view of both intended parents)

Desired Directives (represents the views of both intended parents)

Note: an embryo biopsy is taken most often at day 5 and all 23 pairs of chromosomes are examined including the two sex chromosomes in time for your embryo transfer. Your fertility doctor will be able to explain this to you in more detail, or a member of our nursing staff will gladly provide you with more information.

Background Information


Emergency Contact


By my signature below, I certify that the above information is complete and correct. I have not omitted any information that would make above information inaccurate or misleading. I certify that the above information I have provided id true and correct to best of my knowledge and belief. I understand that any false or withheld information provided on this form may result in disqualification from Bliss Surrogacy Los Angeles program.

Intended Parent #1 (Primary)

Intended Parent #2 (if applicable)

Bliss Surrogacy is committed to protecting and respecting your privacy. We will only use Your personal information to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as Well as other content that may be of interest to you. By checking this box, I give my Express written consent for Bliss Surrogacy to call, text, or email me with marketing Offers or other messages regarding services about which I have inquired at the Phone number I have provided.