SURROGATE APPLICATION

Personal Information

Personal Information

Name:*

Age*

Date of Birth *

Height:*

Weight:*

Ethnicity:*

City and State:*

Are you a permanent U.S. resident or citizen?*

Yes

Have you ever given birth? (not qualified for surrogacy if your answer is No, no need to continue)*

Yes

Number of Children:*

Vaginal Deliveries:*

C-Section Deliveries:*

Previous Surrogate?*

Yes

Insurance:*

Yes

If answer “Yes” to above, insurance company:

Termination of pregnancy if doctor or IP requests:*

Yes

Have you used any form of tobacco or vape in the past 12 months?*

Yes

Have you used any form of marijuana in the past 12 months?*

Yes

Are you exposed to any form of tobacco including vape?*

Yes

Are you exposed to any form of marijuana?*

Yes

Are you actively parenting at least one of your children?*

Yes

Have you ever been convicted of a felony?*

Yes

In the past 12 months have you received a tattoo or piercing?*

Yes

Type of relationship:*

Single/Divorced (not in a relationship)

Single/Divorced (in a relationship)

Married

Spouse/Partner Name (if applicable):

Do you have a car for all the appointments?*

Yes

Are you employed outside of the home?*

Yes

If answer “Yes” to above, your current occupation:

Is your spouse/partner employed?*

Yes

N/A

If answer “Yes” to above, your spouse occupation:

Did you graduate from high school?*

Yes

Highest level of education*

How many sexual partners have you had in the past 12 months*

Birth control method if any*

1/5

Psychological History

Do you now or have you ever taken any medications for psychiatric reasons?*

Yes

Have you ever been treated at a psychiatric hospital?*

Yes

Have you ever experienced psychological, physical or sexual abuse?*

Yes

Have you ever taken antidepressants?*

Yes

Have you ever gone to therapy or counseling?*

Yes

Have you ever attempted suicide?*

Yes

Have you ever been treated for alcohol abuse?*

Yes

Have you ever been treated for substance abuse?*

Yes

2/5

Medical History

Do you or your partners have any STD's or STI's treated or untreated?*

Yes

Do you have regular menstrual cycles?*

Yes

Do you have any current or past medical issues?*

Yes

Do you have an untreated hypo or hyper thyroid?*

Yes

Are you at risk for AIDS?*

Yes

Do you do ANY drugs including medical marijuana?*

Yes

Have you ever had surgery?*

Yes

3/5

Pregnancy History

How many times have you been pregnant?*

How many live births?*

How many children do you have?*

How old are they?

Do they live with you?*

Yes

Date of delivery #1*

Birth Weeks (Delivery 1)*

Birth Weight (Delivery 1)*

Full term:*

Yes

Surrogate Pregnancy?

Yes

Vaginal or C-Section:*

Singleton or Multiple:*

Complications with pregnancy:*

Delivery Hospital:*

Date of delivery #2

Birth Weeks (Delivery 2)

Birth Weight (Delivery 2)

Full term:

Yes

Surrogate Pregnancy?

Yes

Vaginal or C-Section:

Singleton or Multiple:

Complications with pregnancy:

Delivery Hospital:

Date of delivery #3

Birth Weeks (Delivery 3)

Birth Weight (Delivery 3)

Full term:

Yes

Surrogate Pregnancy?

Yes

Vaginal or C-Section:

Singleton or Multiple:

Complications with pregnancy:

Delivery Hospital:

Date of delivery #4

Birth Weeks (Delivery 4)

Birth Weight (Delivery 4)

Full term:

Yes

Surrogate Pregnancy?

Yes

Vaginal or C-Section:

Singleton or Multiple:

Complications with pregnancy:

Delivery Hospital:

Have you ever experienced infertility?*

Yes

Have you ever delivered a child with a genetic abnormality or birth defect?*

Yes

Have you ever placed a child up for adoption?*

Yes

4/5

Surrogacy

Are you willing to work with Intended Parent(s) that does not speak English (translation provided)?*

Yes

Are you willing to work with heterosexual couples?*

Yes

Are you willing to work with heterosexual singles?*

Yes

Are you willing to work with same sex couples?*

Yes

Are you willing to work with gay singles?*

Yes

Are you willing to reduce caffeine during pregnancy?*

Yes

Are you willing to carry for an HIV+ intended parent(s) through SPAR or HART program?*

Yes

Not Sure

Not sure? Click here to learn more.(after reviewing the info in a new window, return to the previous window to resume your application.)

Are you willing to carry for HEP B+ Intended Parents*

Yes

Not Sure

Not sure? Click here to learn more.(after reviewing hte info in a new window, return to the previous window to resume your application.)

Are you willing to have the Intended Parent(s) present during the delivery?*

Yes

Is there anyone you would like to be there for the delivery (example: spouse/partner, mother, sister or friend):*

Would you be comfortable with your Intended Parent(s) attending doctors’ appointments?*

How many embryos are you willing to transfer? *

How many transfer attempts are you willing to attempt?*

Are you willing to leave termination choices up to the Intended Parent(s) in the case of a serious birth defect?*

Are you willing to leave termination choices up to the Intended Parent(s) in the case of a non-life threatening condition?*

If carrying triplets or more are you willing to reduce?*

Yes

If recommended by a doctor are you willing to be placed on bedrest ?*

Yes

When are you ready to begin?*

Describe your support system:*

Do you have childcare available during pregnancy?*

How did you hear about us?*

If you were referred to our agency, list the name of the referral:

Please submit a photo (or photos) of yourself. *

Phone number (Internal Use Only):*

Email (Internal Use Only):*

Upload Image 1*

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By checking this box you confirm that the information given in this form is true, complete and accurate.*

Yes

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5/5

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