CHARLOTTE H. DANCIU, P.A. 202 N. Swinton Avenue Delray Beach, FL 33444 (561) 330-6700 Fax# (561) 330-2446 www.adoption-surrogacy.com PRELIMINARY INFORMATION Who may we thank for referring you?______________________________ COMMISSIONING PARENT COMMISSIONING PARENT     Name :_______________________________ Name: ______________________________     Address: _____________________________ Address: _____________________________     _____________________________________ _____________________________________     How long: _________ Own: _____ Rent: ______ How long: _________ Own: _____ Rent: ______     Birthplace: ______________________________ Birthplace: ______________________________     Date of Birth: ____________________________ Date of Birth: ____________________________     Age: ______ Soc. Sec. #: __________________ Age: ______ Soc. Sec. #: __________________     Physical Description: Ht._______ Wt. _________ Physical Description: Ht._______ Wt. _________     Eyes: _____________ Hair: ________________ Eyes: _____________ Hair: ________________     Ethnic Origin: ____________________________ Ethnic Origin: ____________________________     Religion: ________________________________ Religion: ________________________________     Marriage Date: ___________________________ Marriage Date: ___________________________     Home Phone Number: ______________________ Home Phone Number: ______________________     Cell Phone Number: _______________________ Cell Phone Number: _______________________     E-mail address: ___________________________ E-mail address: ___________________________     Children:       _________________________ Age: ________   _________________________ Age: ________   _________________________ Age: ________           Highest Grade Completed: ____________________ Highest Grade Completed: ____________________     Subject Matter Studied: ______________________ Subject Matter Studied: ______________________     Special Interests or Talents: ____________________ Special Interests or Talents: ____________________     _________________________________________ _________________________________________     _________________________________________ _________________________________________     Military Service: ____________________________ Military Service: ____________________________     Employer: _________________________________ Employer: _________________________________     Address: __________________________________ Address: __________________________________     _________________________________________ _________________________________________     Phone Number: ____________________________ Phone Number: ____________________________     Occupation: _______________________________ Occupation: _______________________________     Approx. Annual Income: $____________________ Approx. Annual Income: $____________________         Have you ever been arrested or convicted of a Crime other than a Minor Traffic Violation? (If the answer to this question is "yes", please explain on an attached sheet of paper.)     Yes: __________ No: _________ Yes: __________ No: _________     Do you drink alcohol? Yes: ________ No: ________ Do you drink alcohol? Yes: ________ No: ________     Do you smoke? Yes: _________ No: _________ Do you smoke? Yes: _________ No: _________     Health Insurance Company:       Name: ____________________________________       Address: __________________________________       _________________________________________       _________________________________________       Phone Number: ____________________________           Family Medical History:       Any serious or chronic illness including mental or psychiatric treatment?     ______________________________________ ____________________________________     ______________________________________ ____________________________________     Has your inability to have a child been diagnosed? ______________ Reason? __________________________________       _______________________________________________________________________________     _______________________________________________________________________________     Have you applied to other Surrogate Agencies/Attorneys?_________ Where? ___________________     ______________________________________________________________________________     ______________________________________________________________________________     Answer as Applicable:       Are you interested in Gestational or Traditional Surrogacy? ____________________________     Will you utilize donor sperm, oocytes or embryos? ________________________     Have you identified a surrogate? _______________       SURROGATE INFORMATION     SURROGATE'S NAME, ADDRESS AND PHONE NUMBERS: ________________________       __________________________________________________________________________     __________________________________________________________________________     SURROGATE'S SOCIAL SECURITY NUMBER   _______________________________       SURROGATE'S DRIVER'S LICENSE NUMBER:   _______________________________       SURROGATE'S HUSBAND NAME: ____________________________________________     SURROGATE'S HUSBAND'S SOCIAL SECURITY NUMBER ________________________________       SURROGATE'S HUSBAND'S DRIVER'S LICENSE NUMBER ________________________________       SURROGATE'S INSURANCE COMPANY: ______________________________________     DATE OF SUCCESSFUL INSEMINATION /TRANSFER: __________________________     DATE OF CONFIRMATION OF PREGNANCY: _______________________________     NAME, ADDRESS AND PHONE NUMBER OF FERTILITY PHYSICIAN: _____________     __________________________________________________________________________     __________________________________________________________________________     NAME, ADDRESS AND PHONE NUMBER OF OBSTETRICIAN: ___________________     __________________________________________________________________________     __________________________________________________________________________     EXPECTED DATE OF BIRTH OF CHILD:   __________________________________________       NUMBER OF CHILDREN EXPECTED, i.e., TWINS, TRIPLETS: ___________________________       EXPECTED HOSPITAL FOR CHILD'S BIRTH:   ______________________________________       CITY, COUNTY & STATE OF CHILD'S ANTICIPATED BIRTH: ______________________     ___________________________________________________________________________     LEGAL NAME CHILD SHALL BE GIVEN: _______________________________________     EXPECTED HEALTH INSURANCE COMPANY FOR CHILD: _______________________     ___________________________________________________________________________     ********PLEASE ENCLOSE A RECENT FAMILY PHOTOGRAPH********     Signed this _________ day of ____________, 20___.               _________________________________ _________________________________ Commissioning Parent Commissioning Parent