Surrogate Application

Name *

First

Last

DOB (MM/DD/YYYY) *

Partner's Name

First

Last

Partner's DOB (MM/DD/YYYY)

Address *

How long have you lived at the above address? *

If less than 2 years at current address, please list prior addresses. *

Home Phone Number *

Cell Phone Number *

Email *

Emergency Contact *

Relationship to you *

Phone Number *

Email

Height (in feet/in) *

Weight (in lb) *

Blood Type *

Ethnicity *

Religion

Natural Hair Color

Natural Eye Color

Hair Type

Complexion

Do you speak any other languages? Please list.

Marital Status *

What is your method of transportation? *

Are you willing to travel out of state? *

Yes
No
Undecided

Do you have regular period? *

Yes
No

How long is your period cycle? *

How many days does your period last? *

Do you have pain/cramping during your period? *

Yes
No
Occasionally

Do you have spotting or bleeding between periods?

Yes
No
Occasionally

Are you currently sexual active? *

Yes
No

How many partners have you had in the past 5 years?

What is your current method of birth control? *

How many biological children do you have? *

Number of vaginal delivery *

Number of C-Section *

Have you ever had a miscarriage? *

Yes
No

Have you ever had an abortion? *

Yes
No

Have you ever had a stillbirth? *

Yes
No

Child # 1 *

Child # 2

Child # 3

Child # 4

Please list any complications you had for each delivery. *

Please list weeks at birth for each child. *

Please list any health problems for each child. *

Do you have any of the following conditions during your pregnancy? Please check all that apply. *

If you checked any of the above, please describe in details.

When was the last time you had a pap smear?

Pap Smear Result

Normal
Abnormal
Don't know / Not applicable

When was the last time you received a Hepatitis B vaccination?

If you have never received Hepatitis B vaccination, are you willing to receive it? *

Yes
No

If a booster shop is needed, are you willing to receive it? *

Yes
No

When was the last time you had HIV/AIDS screening?

HIV/AIDS screening result

Normal
Abnormal
Don't know / Not applicable

Have you ever been diagnosed with any of the following? Please check all that apply. *

If you checked any of the above, please describe treatment course.

Has your partner ever been diagnosed with any of the following? Please check all that apply. *

If you checked any of the above, please describe treatment course.

Describe what type of food your regular diet is consisted of. *

Do you drink alcohol? If so, how often? *

Do you smoke? If so, how often? *

Are your currently taking any medications? If so, please list. *

Please list any food and drug allergies. *

Have you ever had any surgeries? If so, please list what type, reason, and if you had any complications. *

What are your thoughts on surrogacy? Why do you want to be a surrogate? *

Is your partner supportive of you becoming a surrogate? *

Yes
No
Don't know

Are your family/friends supportive of you becoming a surrogate? *

Yes
No
Don't know

Who would you consider to be the key support during your surrogacy journey? *

Multiples are very common with surrogacy. Are you willing to carry... (Please check all that apply.) *

Singleton
Twins
Triplets

Termination and fetal reduction are sometimes recommended to ensure the safety of surrogate and baby(s). Are you willing to terminate/reduce ... (Please check all that apply.) *

Based on Intended Parents' personal choices
If medically necessary
Reduce triplets to twins if medically recommended
Reduce twins to a singleton if medically recommended
Undergo amniocentesis if medically recommended or requested by Intended Parents
Undergo CVS genetic testing/screening if medically recommended or requested by Intended Parents

Please describe your personality. *

What are your hobbies / interests? *

Please describe one of your normal days. *

What is your occupation and work schedule? *

How would you describe your relationship with your partner? *

What is your partner's occupation and work schedule? *

Please list the people and their age who are living with you. *

Who will be able to provide child care and assistance with daily tasks in the event of bed rest? *

How did you hear about us? *

Comments/ Questions / Concerns

Electronic Signature *

Please enter your first and last name in this field.