{"id":3627,"date":"2024-11-22T17:13:55","date_gmt":"2024-11-22T09:13:55","guid":{"rendered":"https:\/\/sunshine.wpsite.tw\/?page_id=3627"},"modified":"2024-11-22T17:20:15","modified_gmt":"2024-11-22T09:20:15","slug":"surrogate-form","status":"publish","type":"page","link":"https:\/\/sunshine.wpsite.tw\/ja\/surrogate-form\/","title":{"rendered":"Surrogate Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3627\" class=\"elementor elementor-3627\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-4858b35 elementor-section-full_width elementor-section-height-min-height elementor-section-height-default elementor-section-items-middle\" data-id=\"4858b35\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-f9378ab\" data-id=\"f9378ab\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-bbf8161 elementor-widget elementor-widget-heading\" data-id=\"bbf8161\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">SURROGATE APPLICATION<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t<div class=\"elementor-element elementor-element-1cd21d5 e-flex e-con-boxed e-con e-parent\" data-id=\"1cd21d5\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-801437e pp-wpforms-labels-yes pp-wpforms-form-button-custom elementor-widget elementor-widget-pp-wpforms\" data-id=\"801437e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"pp-wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"pp-contact-form pp-wpforms pp-custom-radio-checkbox\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"wpforms-container \" id=\"wpforms-3617\"><form id=\"wpforms-form-3617\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"3617\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/ja\/wp-json\/wp\/v2\/pages\/3627?wpforms_form_id=3617\" data-token=\"edd9a09535aeb2c363603b6a5495ea28\" data-token-time=\"1776279230\"><noscript class=\"wpforms-error-noscript\">\u3053\u306e\u30d5\u30a9\u30fc\u30e0\u306b\u5165\u529b\u3059\u308b\u306b\u306f\u3001\u30d6\u30e9\u30a6\u30b6\u30fc\u3067 JavaScript \u3092\u6709\u52b9\u306b\u3057\u3066\u304f\u3060\u3055\u3044\u3002<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-3617-field_1-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"1\"><div id=\"wpforms-3617-field_1\" class=\"wpforms-field-medium wpforms-field-row\"><div class=\"MW5IWV\" id=\"bgLayers_comp-lbr17bve\">\n<h2 class=\"VgO9Yg\" id=\"bgMedia_comp-lbr17bve\">Personal information<\/h2>\n<\/div>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-3617-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_2\">Name (First, Middle, Last) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3617-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" required><\/div><div id=\"wpforms-3617-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_3\">Primary Race <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3617-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" required><\/div><div id=\"wpforms-3617-field_4-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_4\">Date of birth <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-3617-field_4\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-small\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][4][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-3617-field_5-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"5\"><div id=\"wpforms-3617-field_5\" class=\"wpforms-field-medium wpforms-field-row\"><div class=\"MW5IWV\" id=\"bgLayers_comp-lbr17bve\">\n<h2 class=\"VgO9Yg\" id=\"bgMedia_comp-lbr17bve\">Address<\/h2>\n<\/div>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-3617-field_6-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"6\"><label class=\"wpforms-field-label wpforms-label-hide\">Address<\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-3617-field_6\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][6][address1]\" ><label for=\"wpforms-3617-field_6\" class=\"wpforms-field-sublabel after\">\u4f4f\u62401<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-3617-field_6-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][6][address2]\" ><label for=\"wpforms-3617-field_6-address2\" class=\"wpforms-field-sublabel after\">\u4f4f\u62402<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-3617-field_6-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][6][city]\" ><label for=\"wpforms-3617-field_6-city\" class=\"wpforms-field-sublabel after\">\u5e02\u533a\u753a\u6751<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-3617-field_6-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][6][state]\" ><option class=\"placeholder\" value=\"\" selected disabled>--- state \u3092\u9078\u629e ---<\/option><option value=\"AL\" >\u30a2\u30e9\u30d0\u30de\u5dde<\/option><option value=\"AK\" >\u30a2\u30e9\u30b9\u30ab\u5dde<\/option><option value=\"AZ\" >\u30a2\u30ea\u30be\u30ca\u5dde<\/option><option value=\"AR\" >\u30a2\u30fc\u30ab\u30f3\u30bd\u30fc\u5dde<\/option><option value=\"CA\" >\u30ab\u30ea\u30d5\u30a9\u30eb\u30cb\u30a2\u5dde<\/option><option value=\"CO\" >\u30b3\u30ed\u30e9\u30c9\u5dde<\/option><option value=\"CT\" >\u30b3\u30cd\u30c1\u30ab\u30c3\u30c8\u5dde<\/option><option value=\"DE\" >\u30c7\u30e9\u30a6\u30a7\u30a2\u5dde<\/option><option value=\"DC\" >\u30b3\u30ed\u30f3\u30d3\u30a2\u7279\u5225\u533a<\/option><option value=\"FL\" >\u30d5\u30ed\u30ea\u30c0\u5dde<\/option><option value=\"GA\" >\u30b8\u30e7\u30fc\u30b8\u30a2<\/option><option value=\"HI\" >\u30cf\u30ef\u30a4<\/option><option value=\"ID\" >\u30a2\u30a4\u30c0\u30db\u5dde<\/option><option value=\"IL\" >\u30a4\u30ea\u30ce\u30a4\u5dde<\/option><option value=\"IN\" >\u30a4\u30f3\u30c7\u30a3\u30a2\u30ca<\/option><option value=\"IA\" >\u30a2\u30a4\u30aa\u30ef\u5dde<\/option><option value=\"KS\" >\u30ab\u30f3\u30b6\u30b9\u5dde<\/option><option value=\"KY\" >\u30b1\u30f3\u30bf\u30c3\u30ad\u30fc<\/option><option value=\"LA\" >\u30eb\u30a4\u30b8\u30a2\u30ca\u5dde<\/option><option value=\"ME\" >\u30e1\u30a4\u30f3\u5dde<\/option><option value=\"MD\" >\u30e1\u30ea\u30fc\u30e9\u30f3\u30c9\u5dde<\/option><option value=\"MA\" >\u30de\u30b5\u30c1\u30e5\u30fc\u30bb\u30c3\u30c4\u5dde<\/option><option value=\"MI\" >\u30df\u30b7\u30ac\u30f3\u5dde<\/option><option value=\"MN\" >\u30df\u30cd\u30bd\u30bf\u5dde<\/option><option value=\"MS\" >\u30df\u30b7\u30b7\u30c3\u30d4\u30fc\u5dde<\/option><option value=\"MO\" >\u30df\u30ba\u30fc\u30ea\u5dde<\/option><option value=\"MT\" >\u30e2\u30f3\u30bf\u30ca<\/option><option value=\"NE\" >\u30cd\u30d6\u30e9\u30b9\u30ab\u5dde<\/option><option value=\"NV\" >\u30cd\u30d0\u30c0\u5dde<\/option><option value=\"NH\" >\u30cb\u30e5\u30fc\u30cf\u30f3\u30d7\u30b7\u30e3\u30fc\u5dde<\/option><option value=\"NJ\" >\u30cb\u30e5\u30fc\u30b8\u30e3\u30fc\u30b8\u30fc\u5dde<\/option><option value=\"NM\" >\u30cb\u30e5\u30fc\u30e1\u30ad\u30b7\u30b3\u5dde<\/option><option value=\"NY\" >\u30cb\u30e5\u30fc\u30e8\u30fc\u30af<\/option><option value=\"NC\" >\u30ce\u30fc\u30b9\u30ab\u30ed\u30e9\u30a4\u30ca\u5dde<\/option><option value=\"ND\" >\u30ce\u30fc\u30b9\u30c0\u30b3\u30bf<\/option><option value=\"OH\" >\u30aa\u30cf\u30a4\u30aa\u5dde<\/option><option value=\"OK\" >\u30aa\u30af\u30e9\u30db\u30de\u5dde<\/option><option value=\"OR\" >\u30aa\u30ec\u30b4\u30f3\u5dde<\/option><option value=\"PA\" >\u30da\u30f3\u30b7\u30eb\u30d9\u30cb\u30a2\u5dde<\/option><option value=\"RI\" >\u30ed\u30fc\u30c9\u30a2\u30a4\u30e9\u30f3\u30c9\u5dde<\/option><option value=\"SC\" >\u30b5\u30a6\u30b9\u30ab\u30ed\u30e9\u30a4\u30ca\u5dde<\/option><option value=\"SD\" >\u30b5\u30a6\u30b9\u30c0\u30b3\u30bf\u5dde<\/option><option value=\"TN\" >\u30c6\u30cd\u30b7\u30fc\u5dde<\/option><option value=\"TX\" >\u30c6\u30ad\u30b5\u30b9\u5dde<\/option><option value=\"UT\" >\u30e6\u30bf\u5dde<\/option><option value=\"VT\" >\u30d0\u30fc\u30e2\u30f3\u30c8\u5dde<\/option><option value=\"VA\" >\u30d0\u30fc\u30b8\u30cb\u30a2\u5dde<\/option><option value=\"WA\" >\u30ef\u30b7\u30f3\u30c8\u30f3\u5dde<\/option><option value=\"WV\" >\u30a6\u30a7\u30b9\u30c8\u30d0\u30fc\u30b8\u30cb\u30a2\u5dde<\/option><option value=\"WI\" >\u30a6\u30a3\u30b9\u30b3\u30f3\u30b7\u30f3\u5dde<\/option><option value=\"WY\" >\u30ef\u30a4\u30aa\u30df\u30f3\u30b0\u5dde<\/option><\/select><label for=\"wpforms-3617-field_6-state\" class=\"wpforms-field-sublabel after\">\u90fd\u9053\u5e9c\u770c\/\u5dde<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-3617-field_6-postal\" class=\"wpforms-field-address-postal wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][6][postal]\" ><label for=\"wpforms-3617-field_6-postal\" class=\"wpforms-field-sublabel after\">\u90f5\u4fbf\u756a\u53f7<\/label><\/div><\/div><\/div><div id=\"wpforms-3617-field_7-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"7\"><div id=\"wpforms-3617-field_7\" class=\"wpforms-field-medium wpforms-field-row\"><div class=\"MW5IWV\" id=\"bgLayers_comp-lbr17bve\">\n<h2>Contact information<\/h2>\n<\/div>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-3617-field_9-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_9\">Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-3617-field_9\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][9]\" aria-label=\"Phone\" required><\/div><div id=\"wpforms-3617-field_8-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_8\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-3617-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-3617-field_10-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"10\"><div id=\"wpforms-3617-field_10\" class=\"wpforms-field-medium wpforms-field-row\"><div class=\"MW5IWV\" id=\"bgLayers_comp-lbr17bve\">\n<h2>Others<\/h2>\n<\/div>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-3617-field_11-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"11\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-3617-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_12\">Height <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3617-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-3617-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_13\">Weight <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3617-field_13\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][13]\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-3617-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_14\"> BMI <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3617-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-3617-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_15\">Occupation<\/label><input type=\"text\" id=\"wpforms-3617-field_15\" class=\"wpforms-field-medium\" name=\"wpforms[fields][15]\" ><\/div><div id=\"wpforms-3617-field_16-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"16\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-3617-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_17\">Current Relationship Status<\/label><input type=\"text\" id=\"wpforms-3617-field_17\" class=\"wpforms-field-medium\" name=\"wpforms[fields][17]\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-3617-field_18-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_18\">How many years have you been together?:<\/label><input type=\"text\" id=\"wpforms-3617-field_18\" class=\"wpforms-field-medium\" name=\"wpforms[fields][18]\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-3617-field_19-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_19\">Name of partner\/spouse(First, Middle, Last)<\/label><input type=\"text\" id=\"wpforms-3617-field_19\" class=\"wpforms-field-medium\" name=\"wpforms[fields][19]\" ><\/div><div id=\"wpforms-3617-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_20\">What is your level of education?<\/label><input type=\"text\" id=\"wpforms-3617-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" ><\/div><div id=\"wpforms-3617-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_21\">Do you have any religious or spiritual views?<\/label><input type=\"text\" id=\"wpforms-3617-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" ><\/div><div id=\"wpforms-3617-field_23-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"23\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-3617-field_22-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"22\"><label class=\"wpforms-field-label\">Are you able to attend all local appointments? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_22\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_22_1\" name=\"wpforms[fields][22]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_22_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_22_2\" name=\"wpforms[fields][22]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_22_2\">No<\/label><\/li><\/ul><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-3617-field_24-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"24\"><label class=\"wpforms-field-label\">Are you actively parenting at least one of your own children? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_24\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_24_1\" name=\"wpforms[fields][24]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_24_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_24_2\" name=\"wpforms[fields][24]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_24_2\">No<\/label><\/li><\/ul><\/div><\/div><\/div><\/div><div id=\"wpforms-3617-field_25-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_25\">What is your main source of income? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3617-field_25\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][25]\" required><\/div><div id=\"wpforms-3617-field_26-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"26\"><label class=\"wpforms-field-label\">How soon would you like to begin your Surrogacy journey? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_26\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_26_1\" name=\"wpforms[fields][26]\" value=\"Right away\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_26_1\">Right away<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_26_2\" name=\"wpforms[fields][26]\" value=\"6 months\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_26_2\">6 months<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_26_3\" name=\"wpforms[fields][26]\" value=\"1 year\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_26_3\">1 year<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_28-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"28\"><label class=\"wpforms-field-label\">Have you ever applied to any other agencies as a surrogate or egg donor? (if yes what agency?) <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_28\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_28_1\" name=\"wpforms[fields][28]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_28_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_28_2\" name=\"wpforms[fields][28]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_28_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_29-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"29\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_29\">Name of Agency<\/label><input type=\"text\" id=\"wpforms-3617-field_29\" class=\"wpforms-field-medium\" name=\"wpforms[fields][29]\" ><\/div><div id=\"wpforms-3617-field_30-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"30\"><label class=\"wpforms-field-label\">Are there any other people residing in your home other than your children? or your partner? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_30\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_30_1\" name=\"wpforms[fields][30]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_30_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_30_2\" name=\"wpforms[fields][30]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_30_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_31-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"31\"><label class=\"wpforms-field-label\">Are you able to travel out of state for 2-3 days? If travel expenses including childcare and lost wages are reimbursed? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_31\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_31_1\" name=\"wpforms[fields][31]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_31_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_31_2\" name=\"wpforms[fields][31]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_31_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_32-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"32\"><label class=\"wpforms-field-label\">Do you have an existing health insurance policy? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_32\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_32_1\" name=\"wpforms[fields][32]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_32_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_32_2\" name=\"wpforms[fields][32]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_32_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_33-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"33\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_33\">If yes, who is your insurance provider?<\/label><input type=\"text\" id=\"wpforms-3617-field_33\" class=\"wpforms-field-medium\" name=\"wpforms[fields][33]\" ><\/div><div id=\"wpforms-3617-field_34-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"34\"><div id=\"wpforms-3617-field_34\" class=\"wpforms-field-medium wpforms-field-row\"><div class=\"MW5IWV\" id=\"bgLayers_comp-lbr17bve\">\n<h2>Background<\/h2>\n<\/div>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-3617-field_35-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"35\"><label class=\"wpforms-field-label\">Do you drink alcoholic beverages? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_35\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_35_1\" name=\"wpforms[fields][35]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_35_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_35_2\" name=\"wpforms[fields][35]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_35_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_36-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"36\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_36\">If so how often?<\/label><input type=\"text\" id=\"wpforms-3617-field_36\" class=\"wpforms-field-medium\" name=\"wpforms[fields][36]\" ><\/div><div id=\"wpforms-3617-field_37-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"37\"><label class=\"wpforms-field-label\">Have you or your partner ever been investigated by governmental child protective agency? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_37\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_37_1\" name=\"wpforms[fields][37]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_37_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_37_2\" name=\"wpforms[fields][37]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_37_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_38-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"38\"><label class=\"wpforms-field-label\">Do you or your partner currently have any legal cases or claims pending? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_38\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_38_1\" name=\"wpforms[fields][38]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_38_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_38_2\" name=\"wpforms[fields][38]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_38_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_39-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"39\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_39\">If Yes, please explain<\/label><textarea id=\"wpforms-3617-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\" ><\/textarea><\/div><div id=\"wpforms-3617-field_40-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"40\"><label class=\"wpforms-field-label\">Have you or your partner ever been involved in any lawsuit? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_40\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_40_1\" name=\"wpforms[fields][40]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_40_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_40_2\" name=\"wpforms[fields][40]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_40_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_41-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"41\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_41\">If Yes, please explain<\/label><textarea id=\"wpforms-3617-field_41\" class=\"wpforms-field-medium\" name=\"wpforms[fields][41]\" ><\/textarea><\/div><div id=\"wpforms-3617-field_42-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"42\"><label class=\"wpforms-field-label\">Have you ever used illicit drugs (marijuana, cocaine, methamphetamines)? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_42\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_42_1\" name=\"wpforms[fields][42]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_42_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_42_2\" name=\"wpforms[fields][42]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_42_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_43-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"43\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_43\">When was the last time? (please note that you will be tested)<\/label><input type=\"text\" id=\"wpforms-3617-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\" ><\/div><div id=\"wpforms-3617-field_44-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"44\"><label class=\"wpforms-field-label\">Are you exposed to any second-hand smoke at home or at work? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_44\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_44_1\" name=\"wpforms[fields][44]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_44_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_44_2\" name=\"wpforms[fields][44]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_44_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_45-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"45\"><label class=\"wpforms-field-label\">Have you or your partner ever been arrested? (including DUI arrests) <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_45\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_45_1\" name=\"wpforms[fields][45]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_45_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_45_2\" name=\"wpforms[fields][45]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_45_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_46-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"46\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_46\">If Yes, please explain and date<\/label><textarea id=\"wpforms-3617-field_46\" class=\"wpforms-field-medium\" name=\"wpforms[fields][46]\" ><\/textarea><\/div><div id=\"wpforms-3617-field_47-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"47\"><div id=\"wpforms-3617-field_47\" class=\"wpforms-field-medium wpforms-field-row\"><div class=\"MW5IWV\" id=\"bgLayers_comp-lbr17bve\">\n<h2>Medical\/Reproductive History<\/h2>\n<\/div>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-3617-field_48-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"48\"><label class=\"wpforms-field-label\">Have you ever been a surrogate or egg donor before? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_48\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_48_1\" name=\"wpforms[fields][48]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_48_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_48_2\" name=\"wpforms[fields][48]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_48_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_49-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"49\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_49\">If yes, how many times?<\/label><input type=\"text\" id=\"wpforms-3617-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" ><\/div><div id=\"wpforms-3617-field_50-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_50\">Under what circumstances would you consider termination of pregnancy? (I.E. medical advisement, selective reduction, sever abnormalities?) <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-3617-field_50\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][50]\" required><\/textarea><\/div><div id=\"wpforms-3617-field_51-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_51\">How many babies are you willing to carry during this surrogacy journey? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3617-field_51\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][51]\" required><\/div><div id=\"wpforms-3617-field_52-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_52\">How many biological children do you have? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3617-field_52\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][52]\" required><\/div><div id=\"wpforms-3617-field_53-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"53\"><label class=\"wpforms-field-label\">Are all of your children living with you currently?<\/label><ul id=\"wpforms-3617-field_53\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_53_1\" name=\"wpforms[fields][53]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_53_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_53_2\" name=\"wpforms[fields][53]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_53_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_54-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"54\"><label class=\"wpforms-field-label\">Do you have legal custody of your children?<\/label><ul id=\"wpforms-3617-field_54\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_54_1\" name=\"wpforms[fields][54]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_54_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_54_2\" name=\"wpforms[fields][54]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_54_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_55-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"55\"><label class=\"wpforms-field-label\">Do you plan on having more children of your own?<\/label><ul id=\"wpforms-3617-field_55\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_55_1\" name=\"wpforms[fields][55]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_55_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_55_2\" name=\"wpforms[fields][55]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_55_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_57-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_57\">What is your current birth control method?<\/label><input type=\"text\" id=\"wpforms-3617-field_57\" class=\"wpforms-field-medium\" name=\"wpforms[fields][57]\" ><\/div><div id=\"wpforms-3617-field_56-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"56\"><label class=\"wpforms-field-label\">Do you have a regular menstrual cycle? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_56\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_56_1\" name=\"wpforms[fields][56]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_56_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_56_2\" name=\"wpforms[fields][56]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_56_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_58-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"58\"><label class=\"wpforms-field-label\">Do you have any past or current medical issues? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_58\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_58_1\" name=\"wpforms[fields][58]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_58_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_58_2\" name=\"wpforms[fields][58]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_58_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_59-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"59\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_59\">If yes, please explain<\/label><textarea id=\"wpforms-3617-field_59\" class=\"wpforms-field-medium\" name=\"wpforms[fields][59]\" ><\/textarea><\/div><div id=\"wpforms-3617-field_60-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"60\"><label class=\"wpforms-field-label\">Are you allergic to any medication? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_60\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_60_1\" name=\"wpforms[fields][60]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_60_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_60_2\" name=\"wpforms[fields][60]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_60_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_61-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"61\"><label class=\"wpforms-field-label\">Have you ever been prescribed any medications in the last 5 years? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_61\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_61_1\" name=\"wpforms[fields][61]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_61_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_61_2\" name=\"wpforms[fields][61]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_61_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_62-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"62\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_62\">If yes, please explain<\/label><textarea id=\"wpforms-3617-field_62\" class=\"wpforms-field-medium\" name=\"wpforms[fields][62]\" ><\/textarea><\/div><div id=\"wpforms-3617-field_63-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"63\"><label class=\"wpforms-field-label\">Have you had any surgeries? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_63\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_63_1\" name=\"wpforms[fields][63]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_63_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_63_2\" name=\"wpforms[fields][63]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_63_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_64-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"64\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_64\">If yes, please list all reasons for surgery and month\/year of surgery:<\/label><textarea id=\"wpforms-3617-field_64\" class=\"wpforms-field-medium\" name=\"wpforms[fields][64]\" ><\/textarea><\/div><div id=\"wpforms-3617-field_65-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"65\"><label class=\"wpforms-field-label\">Have you ever been diagnosed with : <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_65\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_65_1\" name=\"wpforms[fields][65][]\" value=\"TB\/exposed to TB\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_65_1\">TB\/exposed to TB<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_65_2\" name=\"wpforms[fields][65][]\" value=\"Cancer\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_65_2\">Cancer<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_65_3\" name=\"wpforms[fields][65][]\" value=\"Irregular Heartbeat\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_65_3\">Irregular Heartbeat<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_65_13\" name=\"wpforms[fields][65][]\" value=\"Heart Problems\/Congenital Heart defect\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_65_13\">Heart Problems\/Congenital Heart defect<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_65_12\" name=\"wpforms[fields][65][]\" value=\"Head Injuries\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_65_12\">Head Injuries<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_65_11\" name=\"wpforms[fields][65][]\" value=\"Thyroid\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_65_11\">Thyroid<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_65_10\" name=\"wpforms[fields][65][]\" value=\"Problems\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_65_10\">Problems<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_65_9\" name=\"wpforms[fields][65][]\" value=\"Seizures\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_65_9\">Seizures<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_65_8\" name=\"wpforms[fields][65][]\" value=\"Anemia\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_65_8\">Anemia<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_65_7\" name=\"wpforms[fields][65][]\" value=\"Genital Warts Chlamydia Gonorrhea\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_65_7\">Genital Warts Chlamydia Gonorrhea<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_65_6\" name=\"wpforms[fields][65][]\" value=\"Genital Herpes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_65_6\">Genital Herpes<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_65_16\" name=\"wpforms[fields][65][]\" value=\"Have you ever been diagnosed with Syphilis?\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_65_16\">Have you ever been diagnosed with Syphilis?<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_65_15\" name=\"wpforms[fields][65][]\" value=\"HIV\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_65_15\">HIV<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_65_14\" name=\"wpforms[fields][65][]\" value=\"Hepatitis B Hepatitis C\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_65_14\">Hepatitis B Hepatitis C<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_65_19\" name=\"wpforms[fields][65][]\" value=\"Ovarian Cysts\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_65_19\">Ovarian Cysts<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_65_18\" name=\"wpforms[fields][65][]\" value=\"HPV\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_65_18\">HPV<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_66-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"66\"><label class=\"wpforms-field-label\">Have you ever had any miscarriages? This excludes any chemical pregnancies (where the heartbeat was never detected) <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_66\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_66_1\" name=\"wpforms[fields][66]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_66_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_66_2\" name=\"wpforms[fields][66]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_66_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_67-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"67\"><label class=\"wpforms-field-label\">Have you had any abortions? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_67\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_67_1\" name=\"wpforms[fields][67]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_67_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_67_2\" name=\"wpforms[fields][67]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_67_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_68-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"68\"><label class=\"wpforms-field-label\">Have you been vaccinated for covid-19? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_68\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_68_1\" name=\"wpforms[fields][68]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_68_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_68_2\" name=\"wpforms[fields][68]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_68_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_69-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"69\"><div id=\"wpforms-3617-field_69\" class=\"wpforms-field-medium wpforms-field-row\"><div class=\"MW5IWV\" id=\"bgLayers_comp-lbr17bve\">\n<h2>Pregnancy #1<\/h2>\n<\/div>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-3617-field_70-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"70\"><label class=\"wpforms-field-label\">Was this pregnancy for yourself or a surrogacy journey?<\/label><ul id=\"wpforms-3617-field_70\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_70_1\" name=\"wpforms[fields][70]\" value=\"Myself\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_70_1\">Myself<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_70_2\" name=\"wpforms[fields][70]\" value=\"Surrogacy journey\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_70_2\">Surrogacy journey<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_72-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"72\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-3617-field_71-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"71\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_71\">Date of delivery<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-3617-field_71\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][71][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-3617-field_73-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"73\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_73\">Weeks of gestation<\/label><input type=\"text\" id=\"wpforms-3617-field_73\" class=\"wpforms-field-medium\" name=\"wpforms[fields][73]\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-3617-field_74-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"74\"><label class=\"wpforms-field-label\">Any complications?<\/label><ul id=\"wpforms-3617-field_74\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_74_1\" name=\"wpforms[fields][74]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_74_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_74_2\" name=\"wpforms[fields][74]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_74_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_75-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"75\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_75\">If yes, please explain<\/label><textarea id=\"wpforms-3617-field_75\" class=\"wpforms-field-medium\" name=\"wpforms[fields][75]\" ><\/textarea><\/div><div id=\"wpforms-3617-field_76-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"76\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_76\">Number of babies delivered?<\/label><input type=\"text\" id=\"wpforms-3617-field_76\" class=\"wpforms-field-medium\" name=\"wpforms[fields][76]\" ><\/div><div id=\"wpforms-3617-field_77-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"77\"><label class=\"wpforms-field-label\">Vaginal or C-section?<\/label><ul id=\"wpforms-3617-field_77\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_77_1\" name=\"wpforms[fields][77]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_77_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_77_2\" name=\"wpforms[fields][77]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_77_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_78-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"78\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_78\">If yes, please explain why?<\/label><textarea id=\"wpforms-3617-field_78\" class=\"wpforms-field-medium\" name=\"wpforms[fields][78]\" ><\/textarea><\/div><div id=\"wpforms-3617-field_79-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"79\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_79\">Childs Birth Weight<\/label><input type=\"text\" id=\"wpforms-3617-field_79\" class=\"wpforms-field-medium\" name=\"wpforms[fields][79]\" ><\/div><div id=\"wpforms-3617-field_80-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"80\"><div id=\"wpforms-3617-field_80\" class=\"wpforms-field-medium wpforms-field-row\"><div class=\"MW5IWV\" id=\"bgLayers_comp-lbr17bve\">\n<h2>Pregnancy #2<\/h2>\n<\/div>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-3617-field_90-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"90\"><label class=\"wpforms-field-label\">Was this pregnancy for yourself or a surrogacy journey?<\/label><ul id=\"wpforms-3617-field_90\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_90_1\" name=\"wpforms[fields][90]\" value=\"Myself\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_90_1\">Myself<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_90_2\" name=\"wpforms[fields][90]\" value=\"Surrogacy journey\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_90_2\">Surrogacy journey<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_87-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"87\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-3617-field_88-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"88\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_88\">Date of delivery<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-3617-field_88\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][88][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-3617-field_89-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"89\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_89\">Weeks of gestation<\/label><input type=\"text\" id=\"wpforms-3617-field_89\" class=\"wpforms-field-medium\" name=\"wpforms[fields][89]\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-3617-field_86-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"86\"><label class=\"wpforms-field-label\">Any complications? <\/label><ul id=\"wpforms-3617-field_86\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_86_1\" name=\"wpforms[fields][86]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_86_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_86_2\" name=\"wpforms[fields][86]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_86_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_85-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"85\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_85\">If yes, please explain<\/label><textarea id=\"wpforms-3617-field_85\" class=\"wpforms-field-medium\" name=\"wpforms[fields][85]\" ><\/textarea><\/div><div id=\"wpforms-3617-field_84-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"84\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_84\">Number of babies delivered?<\/label><input type=\"text\" id=\"wpforms-3617-field_84\" class=\"wpforms-field-medium\" name=\"wpforms[fields][84]\" ><\/div><div id=\"wpforms-3617-field_82-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"82\"><label class=\"wpforms-field-label\">Vaginal or C-section?<\/label><ul id=\"wpforms-3617-field_82\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_82_1\" name=\"wpforms[fields][82]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_82_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_82_2\" name=\"wpforms[fields][82]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_82_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_83-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"83\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_83\">If yes, please explain why?<\/label><textarea id=\"wpforms-3617-field_83\" class=\"wpforms-field-medium\" name=\"wpforms[fields][83]\" ><\/textarea><\/div><div id=\"wpforms-3617-field_81-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"81\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_81\">Childs Birth Weight<\/label><input type=\"text\" id=\"wpforms-3617-field_81\" class=\"wpforms-field-medium\" name=\"wpforms[fields][81]\" ><\/div><div id=\"wpforms-3617-field_91-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"91\"><div id=\"wpforms-3617-field_91\" class=\"wpforms-field-medium wpforms-field-row\"><div class=\"MW5IWV\" id=\"bgLayers_comp-lbr17bve\">\n<h2>Psychological History<\/h2>\n<\/div>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-3617-field_92-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"92\"><label class=\"wpforms-field-label\">Have you or your partner if applicable ever had psychological counseling? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_92\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_92_1\" name=\"wpforms[fields][92]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_92_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_92_2\" name=\"wpforms[fields][92]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_92_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_93-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"93\"><label class=\"wpforms-field-label\">Have you ever been prescribed any psychiatric medications? (including anti-depressants and anti-anxiety medications) <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_93\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_93_1\" name=\"wpforms[fields][93]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_93_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_93_2\" name=\"wpforms[fields][93]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_93_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_94-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"94\"><label class=\"wpforms-field-label\">Have you ever been diagnosed with any of the following? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_94\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_94_1\" name=\"wpforms[fields][94][]\" value=\"Drug or alcohol addiction\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_94_1\">Drug or alcohol addiction<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_94_2\" name=\"wpforms[fields][94][]\" value=\"An eating disorder\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_94_2\">An eating disorder<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_94_3\" name=\"wpforms[fields][94][]\" value=\"Schizophrenia\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_94_3\">Schizophrenia<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_94_6\" name=\"wpforms[fields][94][]\" value=\"Depression\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_94_6\">Depression<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_94_5\" name=\"wpforms[fields][94][]\" value=\"Nervous breakdown\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_94_5\">Nervous breakdown<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_94_4\" name=\"wpforms[fields][94][]\" value=\"Bi-polar disorder\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_94_4\">Bi-polar disorder<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_94_8\" name=\"wpforms[fields][94][]\" value=\"Personality disorder\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_94_8\">Personality disorder<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_94_7\" name=\"wpforms[fields][94][]\" value=\"Anxiety\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_94_7\">Anxiety<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_95-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"95\"><label class=\"wpforms-field-label\">Have you ever been hospitalized for psychiatric care? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_95\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_95_1\" name=\"wpforms[fields][95]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_95_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_95_2\" name=\"wpforms[fields][95]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_95_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_96-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"96\"><label class=\"wpforms-field-label\">Have you ever attempted suicide? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_96\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_96_1\" name=\"wpforms[fields][96]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_96_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_96_2\" name=\"wpforms[fields][96]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_96_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_97-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"97\"><div id=\"wpforms-3617-field_97\" class=\"wpforms-field-medium wpforms-field-row\"><div class=\"MW5IWV\" id=\"bgLayers_comp-lbr17bve\">\n<h2>Surrogacy Questions<\/h2>\n<\/div>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-3617-field_98-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"98\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_98\">Base fee? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3617-field_98\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][98]\" required><\/div><div id=\"wpforms-3617-field_99-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"99\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_99\">Why do you want to become a surrogate? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-3617-field_99\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][99]\" required><\/textarea><\/div><div id=\"wpforms-3617-field_100-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"100\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_100\">What would you like the Intended Parents know about you? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-3617-field_100\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][100]\" required><\/textarea><\/div><div id=\"wpforms-3617-field_101-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"101\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_101\">What kind of relationship would you like with your IP&#039;s during your surrogacy journey? (friendship, very little to NO communication) <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-3617-field_101\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][101]\" required><\/textarea><\/div><div id=\"wpforms-3617-field_102-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"102\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_102\">What kind of relationship would you like after delivery? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-3617-field_102\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][102]\" required><\/textarea><\/div><div id=\"wpforms-3617-field_103-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"103\"><label class=\"wpforms-field-label\">Would you be comfortable with the IP&#039;s in the delivery room? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_103\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_103_1\" name=\"wpforms[fields][103]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_103_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_103_2\" name=\"wpforms[fields][103]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_103_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_104-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"104\"><label class=\"wpforms-field-label\">Would you be willing to pump after delivery? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_104\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_104_1\" name=\"wpforms[fields][104]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_104_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_104_2\" name=\"wpforms[fields][104]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_104_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_105-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"105\"><label class=\"wpforms-field-label\">Are you comfortable having the IP in the transfer room\/or recording the transfer for the IP? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_105\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_105_1\" name=\"wpforms[fields][105]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_105_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_105_2\" name=\"wpforms[fields][105]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_105_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_106-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"106\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_106\">Name at least 3 people who your support system consist of? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-3617-field_106\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][106]\" required><\/textarea><\/div><div id=\"wpforms-3617-field_107-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"107\"><label class=\"wpforms-field-label\">Are you comfortable with injections and taking oral medication for surrogacy? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3617-field_107\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_107_1\" name=\"wpforms[fields][107]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_107_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3617-field_107_2\" name=\"wpforms[fields][107]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_107_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-3617-field_108-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"108\"><div id=\"wpforms-3617-field_108\" class=\"wpforms-field-medium wpforms-field-row\"><div class=\"MW5IWV\" id=\"bgLayers_comp-lbr17bve\">\n<h2>About you<\/h2>\n<\/div>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-3617-field_109-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"109\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_109\">Describe your personality? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-3617-field_109\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][109]\" required><\/textarea><\/div><div id=\"wpforms-3617-field_110-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"110\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_110\">What does your daily routine consist of? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-3617-field_110\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][110]\" required><\/textarea><\/div><div id=\"wpforms-3617-field_111-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"111\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_111\">What do you do for fun? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-3617-field_111\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][111]\" required><\/textarea><\/div><div id=\"wpforms-3617-field_112-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"112\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_112\">What are your hobbies? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-3617-field_112\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][112]\" required><\/textarea><\/div><div id=\"wpforms-3617-field_113-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"113\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_113\">What is your favorite way to spend time with your family? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-3617-field_113\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][113]\" required><\/textarea><\/div><div id=\"wpforms-3617-field_115-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"115\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-3617-field_116-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"116\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_116\">What is your favorite flower? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3617-field_116\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][116]\" required><\/div><div id=\"wpforms-3617-field_120-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"120\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_120\">What is your favorite way to relax? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3617-field_120\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][120]\" required><\/div><div id=\"wpforms-3617-field_118-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"118\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_118\">What is your favorite dessert, candy or snack food? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3617-field_118\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][118]\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-3617-field_117-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"117\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_117\">What is your favorite color? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3617-field_117\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][117]\" required><\/div><div id=\"wpforms-3617-field_119-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"119\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_119\">What is your favorite Movie or TV show? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3617-field_119\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][119]\" required><\/div><div id=\"wpforms-3617-field_121-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"121\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_121\">Favorite type of jewelry? (I.E. rings, necklaces, or bracelets?) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3617-field_121\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][121]\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-3617-field_122-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"122\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_122\">How did you hear about us? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3617-field_122\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][122]\" required><\/div><div id=\"wpforms-3617-field_123-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"123\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_123\">Can you send us a few pictures of you? <span class=\"wpforms-required-label\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader wpforms-field-required\"\n\t\tdata-field-id=\"123\"\n\t\tdata-form-id=\"3617\"\n\t\tdata-input-name=\"wpforms_3617_123\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages,json\"\n\t\tdata-max-size=\"15728640\"\n\t\tdata-max-file-number=\"5\"\n\t\tdata-post-max-size=\"268435456\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">\u6700\u5927 5 \u500b\u306e\u30d5\u30a1\u30a4\u30eb\u3092\u30a2\u30c3\u30d7\u30ed\u30fc\u30c9\u3067\u304d\u307e\u3059\u3002<\/span>\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-3617-field_123\"\n\t\tname=\"wpforms_3617_123\" required\t\tvalue=\"\">\n<\/div><div id=\"wpforms-3617-field_126-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"126\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-67-33\"><div class=\"wpforms-layout-column wpforms-layout-column-67\" ><div id=\"wpforms-3617-field_124-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"124\"><label class=\"wpforms-field-label wpforms-label-hide\">123<\/label><ul id=\"wpforms-3617-field_124\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-3617-field_124_1\" name=\"wpforms[fields][124][]\" value=\"I swear or affirm that the above and foregoing representations are true and correct to the best of my information, knowledge, and belief.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3617-field_124_1\">I swear or affirm that the above and foregoing representations are true and correct to the best of my information, knowledge, and belief.<\/label><\/li><\/ul><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-3617-field_125-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"125\"><label class=\"wpforms-field-label\" for=\"wpforms-3617-field_125\">Sign date <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-3617-field_125\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][125][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"3617\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/sunshine.wpsite.tw\/ja\/wp-json\/wp\/v2\/pages\/3627\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-3617\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/sunshine.wpsite.tw\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"\u8aad\u307f\u8fbc\u307f\u4e2d\" title=\"\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>SURROGATE APPLICATION Please enable JavaScript in your browser to complete this form. Personal information Name (First, Middle, Last) *Primary Race *Date of birth * Address AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code Contact information Phone *Email * Others LayoutHeight *Weight * BMI *OccupationLayoutCurrent Relationship StatusHow many years have you been together?:Name of partner\/spouse(First, Middle, Last)What is your level of education?Do you have any religious or spiritual views?LayoutAre you able to attend all local appointments? * Yes No Are you actively parenting at least one of your own children? * Yes No What is your main source of income? *How [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"full-width-container","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"default","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"set","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-3627","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/sunshine.wpsite.tw\/ja\/wp-json\/wp\/v2\/pages\/3627","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/sunshine.wpsite.tw\/ja\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/sunshine.wpsite.tw\/ja\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/sunshine.wpsite.tw\/ja\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/sunshine.wpsite.tw\/ja\/wp-json\/wp\/v2\/comments?post=3627"}],"version-history":[{"count":0,"href":"https:\/\/sunshine.wpsite.tw\/ja\/wp-json\/wp\/v2\/pages\/3627\/revisions"}],"wp:attachment":[{"href":"https:\/\/sunshine.wpsite.tw\/ja\/wp-json\/wp\/v2\/media?parent=3627"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}