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Surrogate Intake Page Section 2

Please complete all the forms listed below and provide copies of the

requested documentation.


If you need help filling out or have questions, Amber is glad to help.

Amber 458.207.0523 (text friendly)

Section 2

We need to order your medical records from each of your pregnancies and deliveries. If you have any concerns, or can't remember the name or address of your clinic, reach out to us and we will help!


Please click the link below.

Authorization to Release Medical Records

Fill out the information for each pregnancy on the form. Please include the prenatal care provider and the delivering hospital or facility for each pregnancy.  

Please make sure to list the year before you delivered and your delivery year.  (For example, if you delivered a baby in April of 2015, you would put "2014 & 2015" in the year section.)

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