WE WANT TO KNOW YOU

Human value is the most important thing for us. Therefore, we want to get to know you better to find the way in which we will deliver your baby to you.

Please fill out the following form

What is your sex?

Female

Male

Patient's data

* Name(s)

* Last name

Mother's last name

* Birthdate

* Code

* Cell phone

How do you like to be referred to?

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Couple's information

* Name(s)

* Last name

Mother's last name

Birthdate

* Code

* Cell phone

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I do not have a couple

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Relevant Medical History:

* Do you consume any drugs?

Yes

Not

Briefly describe

* Do you suffer from any illness?

Yes

Not

Briefly describe

* What is your birth gender?

Women

Men

* Have you had any surgery?

Yes

Not

Briefly describe

Relevant Medical History

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In this project you...

* Select only one box

You belong to a heterosexual couple (woman and man)

You belong to a homosexual couple (woman and woman)

You belong to a homosexual couple (man and man)

You will be a single mother by choice

You will be a single parent by choice

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Do you know what a Uterine Surrogacy consists of?:

* Select only one box

It's making embryos in a lab and putting them in my uterus.

It is placing your own embryos in the uterus of a pregnant woman.

It is placing my own or my partner's sperm into another woman's uterus.

It is a legal medical process through which a woman lends her womb to conceive my baby.

Why do you want to perform a Uterine Surrogacy?:

* Select only one box

I can't get pregnant with sexual relations

I am a man and this is the way I can have my baby

I am a woman and I do not have a uterus.

I have done many In Vitros and it doesn't work

Another reason

Briefly describe

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Do you already have information about where, who and how Uterine Surrogacy is performed?:

* Select only one box

No, this is the first time I ask.

Yes, I have information from 1 or more surrogacy agencies

Yes, I have information about 1 or more reproduction centers

*For a proper Uterine Surrogacy process it is required.

* Select only one box

A Gynecologist and a woman that I get

A medical team, a legal team and a surrogate agency

Just a lawyer

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The cost of a Uterine Surrogacy Process from the beginning to having my baby at home with all the legal documents that prove that I am the father or mother, including medical processes, legal processes and compensation to the surrogate is

* Select only one box

$ 400,000 MXN to $ 600,000 MXN

$ 700,000 MXN to $ 900,000 MXN

$ 1,000,000 MXN to $ 1,500,000 MXN

When do you want to start your Uterine Surrogacy process?

* Select only one box

As soon as possible

Next year

I still don't know if I will do it

This year, but I don't know when yet.

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If you are a woman...

* Your menstrual period is:

Regular

Irregular

I don't have my period anymore

* During your menstrual period you have intense pain

Yes

Not

Regarding your obstetric history, please tell us how many:

Pregnancies:

Births:

Cesarean sections:

Abortions:

Curettages:

* Have you already had a study done to find out why pregnancy is not achieved:

Yes

Not

Briefly describe

* You already have a diagnosis for which pregnancy is not achieved:

Yes

Not

Briefly describe

* Have you already had any Reproduction treatment:

Yes

Not

Briefly describe

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You are a man...

* Do you have any erection or ejaculation problems?

Yes

Not

Briefly describe

* You have had semen studies performed before

Yes

Not

Briefly describe

* Have you already had a study done to find out why pregnancy is not achieved:

Yes

Not

Briefly describe

* You already have a diagnosis for which pregnancy is not achieved:

Yes

Not

Briefly describe

* Have you already had any Reproduction treatment:

Yes

Not

Briefly describe

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How did you hear about us?

* ¿Select only one box?

Briefly describe

We greatly appreciate your trust, and we will seek to give you a prompt response that is as close to reality as possible.

Notice of Privacy
Authorization to share personal data

control:

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Finish

WE WANT TO KNOW YOU

Patient's data

Couple's information

Relevant Medical History:

We greatly appreciate your trust, and we will seek to give you a prompt response that is as close to reality as possible.

Notice of Privacy Authorization to share personal data

Notice of Privacy
Authorization to share personal data