If you are interested in being a gestational carrier or traditional surrogate, are in good health, are over twenty-one years of age, live in Pennsylvania or a nearby state (other than New York) and have previously given birth to at least one child, please send Mr. Kalikow an e-mail at LAKalikow@aol.com or call him at 215-682-9100.

Mr. Kalikow represents intended parents who are waiting to find the right person to carry their child. To expedite things, you may wish to complete and send the preliminary questionnaire below.

No attorney/client relationship is established by filling out this questionnaire.
 

Name

Phone

Email

Address

City State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code

Age

Marital Status

How many biological children do you have?

When did you last give birth to a child?

Do you smoke or use tobacco? Yes No

Do you have health insurance that includes coverage for prenatal care and delivery? Yes No

Are you employed and, if so, how? Yes No

Are you interested in being a: Gestational Carrier Traditional Surrogate Both

Comments

 
Thank you for completing this questionnaire. Your interest in being a gestational carrier and/or traditional surrogate is sincerely appreciated.

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