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SURROGATE APPLICATION

Personal information

Name (First, Middle, Last):

Primary Race:

Birth date

Address

Street Address

Street Address Line 2

City

State

Zip code

Contact information

Email

Phone

Others

Height

Weight

BMI

Occupation

Current Relationship Status

How 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?

Are 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 soon would you like to begin your Surrogacy journey?

Right away

6 months

1 year

Have you ever applied to any other agencies as a surrogate or egg donor? (if yes what agency?)

Yes

No

Are there any other people residing in your home other than your children? or your partner?

Yes

No

Are you able to travel out of state for 2-3 days? If travel expenses including childcare and lost wages are reimbursed?

Yes

No

Do you have an existing health insurance policy?

Yes

No

If yes, who is your insurance provider?

Background

Do you drink alcoholic beverages?

Yes

No

If so how often?

Have you or your partner ever been investigated by governmental child protective agency?

Yes

No

Do you or your partner currently have any legal cases or claims pending?

Yes

No

If Yes, please explain

Have you or your partner ever been involved in any lawsuit?

Yes

No

If Yes, please explain

Have you ever used illicit drugs (marijuana, cocaine, methamphetamines)?

Yes

No

When was the last time? (please note that you will be tested)?

Are you exposed to any second-hand smoke at home or at work?

Yes

No

Have you or your partner ever been arrested (including DUI arrests)

Yes

No

If Yes, please explain and date?

Medical/Reproductive History

Have you ever been a surrogate or egg donor before?

Yes

No

If yes, how many times?

Under what circumstances would you consider termination of pregnancy? (I.E. medical advisement, selective reduction, sever abnormalities?)

How many babies are you willing to carry during this surrogacy journey?

How many biological children do you have?

Are all of your children living with you currently?

Yes

No

Do you have legal custody of your children?

Yes

No

Do you plan on having more children of your own?

Yes

No

What is your current birth control method?

Do you have a regular menstrual cycle?

Yes

No

Do you have any past or current medical issues?

Yes

No

If yes, please explain

Are you allergic to any medication?

Yes

No

Have you ever been prescribed any medications in the last 5 years?

Yes

No

If yes, please explain

Have you had any surgeries?

Yes

No

If yes, please list all reasons for surgery and month/year of surgery:

Have you ever been diagnosed with :

TB/exposed to TB

Cancer

Irregular Heartbeat

Heart problems / congenital Heart defect

Head injuries

Thyroid

Problems

Seizures

Anemia

Genital Warts Chlamydia Gonorrhea

Genital Herpes

Have you ever been diagnosed with Syphilis?

HIV

Hepatitis B Hepatitis C

Ovarian Cysts

HPV

Have you ever had any miscarriages? This excludes any chemical pregnancies (where the heartbeat was never detected)

Yes

No

Have you had any abortions?

Yes

No

Pregnancy #1

Was this pregnancy for yourself or a surrogacy journey?

Myself

Surrogacy journey

Date of delivery

Weeks of gestation

Any complications?

Yes

No

If yes, please explain

Number of babies delivered?

Vaginal or C-section?

Yes

No

If yes, please explain why?

Childs Birth Weight:

Pregnancy #2

Was this pregnancy for yourself or a surrogacy journey?

Myself

Surrogacy journey

Date of delivery

Weeks of gestation

Any complications?

Yes

No

If yes, please explain

Number of babies delivered?

Vaginal or C-section?

Yes

No

If yes, please explain why?

Childs Birth Weight:

Have you or your partner if applicable ever had psychological counseling?

Yes

No

Have you ever been prescribed any psychiatric medications (including anti-depressants and anti-anxiety medications)?

Yes

No

Have you ever been diagnosed with any of the following?

Drug or alcohol addiction

An eating disorder

Schizophrenia

Depression

Nervous breakdown

Bi-polar disorder

Personality disorder

Anxiety

Have you ever been hospitalized for psychiatric care?

Yes

No

Have you ever attempted suicide?

Yes

No

Surrogacy Questions

Base fee?

Why do you want to become a surrogate?

What would you like the Intended Parents know about you?

What kind of relationship would you like with your IP's during your surrogacy journey? (friendship, very little to NO communication)

What kind of relationship would you like after delivery?

Would you be comfortable with the IP's in the delivery room?

Yes

No

Would you be willing to pump after delivery?

Yes

No

Are you comfortable having the IP in the transfer room/or recording the transfer for the IP?

Yes

No

Name at least 3 people who your support system consist of?

Are you comfortable with injections and taking oral medication for surrogacy?

Yes

No

About you

Describe your personality?

What does your daily routine consist of?

What do you do for fun?

What are your hobbies?

What is your favorite way to spend time with your family?

What is your favorite flower?

What is your favorite color?

What is your favorite dessert, candy or snack food?

What is your favorite Movie or TV show?

What is your favorite way to relax?

Favorite type of jewelry? I.E. rings, necklaces, or bracelets?)

How did you hear about us?

Can you send us a few pictures of you?

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