{"id":84,"date":"2012-02-22T17:26:22","date_gmt":"2012-02-22T17:26:22","guid":{"rendered":"https:\/\/surrogacy-lawyer.com\/?page_id=84"},"modified":"2012-02-22T17:26:22","modified_gmt":"2012-02-22T17:26:22","slug":"initial-surrogate-form","status":"publish","type":"page","link":"https:\/\/surrogacy-lawyer.com\/zh\/contact-us\/initial-surrogate-form\/","title":{"rendered":"Initial Surrogate Form"},"content":{"rendered":"<script type=\"text\/javascript\">var 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value='\u7f57\u5fb7\u5c9b\u5dde' >\u7f57\u5fb7\u5c9b\u5dde<\/option><option value='\u5357\u5361\u7f57\u6765\u7eb3\u5dde' >\u5357\u5361\u7f57\u6765\u7eb3\u5dde<\/option><option value='\u5357\u8fbe\u79d1\u4ed6\u5dde' >\u5357\u8fbe\u79d1\u4ed6\u5dde<\/option><option value='\u7530\u7eb3\u897f\u5dde' >\u7530\u7eb3\u897f\u5dde<\/option><option value='\u5fb7\u514b\u8428\u65af\u5dde' >\u5fb7\u514b\u8428\u65af\u5dde<\/option><option value='\u72b9\u4ed6\u5dde' >\u72b9\u4ed6\u5dde<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='\u4f5b\u8499\u7279\u5dde' >\u4f5b\u8499\u7279\u5dde<\/option><option value='\u5f17\u5409\u5c3c\u4e9a' >\u5f17\u5409\u5c3c\u4e9a<\/option><option value='\u534e\u76db\u987f\u5dde' >\u534e\u76db\u987f\u5dde<\/option><option value='\u897f\u7ef4\u5409\u5c3c\u4e9a\u5dde' >\u897f\u7ef4\u5409\u5c3c\u4e9a\u5dde<\/option><option value='\u5a01\u65af\u5eb7\u8f9b\u5dde' >\u5a01\u65af\u5eb7\u8f9b\u5dde<\/option><option value='\u6000\u4fc4\u660e\u5dde' >\u6000\u4fc4\u660e\u5dde<\/option><option value='\u6b66\u88c5\u529b\u91cf\u7f8e\u6d32' >\u6b66\u88c5\u529b\u91cf\u7f8e\u6d32<\/option><option value='\u6b66\u88c5\u90e8\u961f\u6b27\u6d32' >\u6b66\u88c5\u90e8\u961f\u6b27\u6d32<\/option><option value='\u6b66\u88c5\u90e8\u961f\u592a\u5e73\u6d0b' >\u6b66\u88c5\u90e8\u961f\u592a\u5e73\u6d0b<\/option><\/select>\n                                        <label for='input_1_2_4' id='input_1_2_4_label' class='gform-field-label gform-field-label--type-sub '>\u5dde<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_2_5_container' >\n                                    <input type='text' name='input_2.5' id='input_1_2_5' value=''    aria-required='true'    \/>\n                                    <label for='input_1_2_5' id='input_1_2_5_label' class='gform-field-label gform-field-label--type-sub '>\u90ae\u653f\u7f16\u7801<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_2.6' id='input_1_2_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\" ><label class='gfield_label gform-field-label' for='input_1_3'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_1_3' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_4\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\" ><label class='gfield_label gform-field-label' for='input_1_4'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_1_4' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_5\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\" ><label class='gfield_label gform-field-label' for='input_1_5'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\" ><label class='gfield_label gform-field-label' for='input_1_6'>Height<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_1_6' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_7\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\" ><label class='gfield_label gform-field-label' for='input_1_7'>Weight<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_8\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\" ><label class='gfield_label gform-field-label' for='input_1_8'>Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_8' id='input_1_8' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Please Choose One...' >Please Choose One...<\/option><option value='American Indian' >American Indian<\/option><option value='Alaskan Native' >Alaskan Native<\/option><option value='Asian American' >Asian American<\/option><option value='Black\/African American' >Black\/African American<\/option><option value='Pacific Islander' >Pacific Islander<\/option><option value='Caucasian\/White' >Caucasian\/White<\/option><option value='Hispanic\/Latino' >Hispanic\/Latino<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_1_9\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\" ><label class='gfield_label gform-field-label' for='input_1_9'>Marital Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_9' id='input_1_9' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Single' >Single<\/option><option value='Married' >Married<\/option><option value='Divorced' >Divorced<\/option><option value='Widowed' >Widowed<\/option><\/select><\/div><\/li><li id=\"field_1_10\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\" ><label class='gfield_label gform-field-label' for='input_1_10'>Number of Pregnancies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_10' id='input_1_10' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_11\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\" ><label class='gfield_label gform-field-label' for='input_1_11'>Number of Deliveries<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_11' id='input_1_11' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_12\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  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ginput_container_select'><select name='input_13' id='input_1_13' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Please Choose One...' >Please Choose One...<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_1_14\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_14\" ><label class='gfield_label gform-field-label' for='input_1_14'>Insurance Company<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_15\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\" ><label class='gfield_label gform-field-label' for='input_1_15'>How 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