Your Surrogacy Application

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Personal Information

Name*

Age*

Date of Birth*

MM slash DD slash YYYY

Height*

Weight*

City and State*

Ethnicity*

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 the intended parent 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

Do you take any medications either over the counter or prescription?*

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

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*

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

Are you currently taking any Anxiety or Anti-Depressant Medications?*

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

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 any medical concerns that are untreated or you are worried about?*

Yes

Do you have an untreated hypo or hyper thyroid?*

Yes

Have you been diagnosed with high cholesterol?*

Yes

Have you had an abnormal pap?*

Yes

Do you have any allergies?*

Yes

Are you at risk for AIDS?*

Yes

Were the results of your last physical normal?*

Yes

Do you do ANY drugs including medical marijuana?*

Yes

Do you take any medications to help you sleep?*

Yes

Have you ever had surgery?*

Yes

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*

Full term*

Yes

Pregnancy Weeks

Surrogate Pregnancy?*

Yes

Vaginal or C-Section*

Singleton or Multiple*

Complications with pregnancy*

Delivery Hospital*

Date of delivery #2

Full term

Yes

Pregnancy Weeks

Vaginal or C-Section

Singleton or Multiple

Complications with pregnancy

Delivery Hospital

Date of delivery #3

Full term

Yes

Pregnancy Weeks

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

Preferred delivery hospital

Your current OB/GYN

Surrogacy

Do you have any concerns about 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 the 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 would you like to have contact with your Intended Parent(s) during the pregnancy?*

How often would you like contact with you Intended Parent(s) during the pregnancy?*

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?*

Are there any conditions under which you would not terminate?*

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 photos of yourself, it is required that you submit at least three photos.*

Max. file size: 1 GB.

Please submit photos of yourself, it is required that you submit at least three photos.*

Max. file size: 1 GB.

Please submit photos of yourself, it is required that you submit at least three photos.*

Max. file size: 1 GB.

Please submit photos of yourself, it is required that you submit at least three photos.

Drop files here or

Max. file size: 1 GB.

Phone number (Internal Use Only)*

Email (Internal Use Only)*

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

Yes