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SURROGATE APPLICATION

First Name

Last Name

Phone Number

Address 1

Address 2

City

State

Zip

Country

How did you hear about us?

Date of last menstrual period?

Birth Date

Height(Feet)

Weight(Pound)

Eye Color

Hair Color

Race/Ethnicity

Blood Group

Marital Status

Education

BASIC REQUIREMENTS

I am a female non-smoker age 21-35

Yes No

I have given birth and raised at least one child Please note that you have to have given birth and raised at least 1 child in order to qualify.

Yes No

Were your pregnancies complicated?

Yes No

Does anyone living in your home, including yourself, smoke, abuse alcohol, or use recreational drugs?

Yes No

I am comfortable taking medication to prepare my uterus for implantation and to help maintain the pregnancy and that medications may be in the form of a pill, vaginal suppository, a patch, or injection

Yes No

Have you received any psychiatric care in the last ten years?

Yes No

I am a citizen of the United States

Yes No

I reside in the state of California

Yes No

I have a reliable car with insurance

Yes No

Are you receiving any federal or state financial assistance?

Yes No

Do you have any ongoing legal disputes?

Yes No

CONSENT

I agree to meet with a licensed mental health professional for a psychological exam

Yes No

I am willing for a staff member to conduct a home visit

Yes No

I understand a background check for myself and my husband/partner will be performed

Yes No

I will allow a full medical examination which will include a vaginal ultrasound, pelvic examination, disease testing, and drug testing

Yes No

I understand that my BMI must be 18 to 29 *

Yes No

Your Occupation

Partner supports surrogacy decision

Alcohol consumption (frequency/amount)

Has your weight changed dramatically in the last five years for reasons other than pregnancy?

If yes to weight change, please explain

Have you or anyone in your home been treated for mental illness?

If yes to mental illness treatment, please explain

List prescription or other drugs you take

Have you ever lived in another country?

If yes to another country, where, when, and for how long

Have you or your partner ever been arrested or convicted of a felony or misdemeanor?

If yes to arrest, please explain

Number of Pregnancies

For each pregnancy, please indicate the following:

Year of pregnancy
Number of months to conceive
Date of delivery
Number of weeks from conception to delivery
Birth weight (pounds and ounces)
Indicate any other details or complications
Name of obstetrician and hospital delivered

You may separate each item with a comma (e.g., "pregnant in 1998, 2 months to conceive, delivered 11/14/1998,...").

Pregnancy #1 details

Pregnancy #2 details

Pregnancy #3 details

Pregnancy #4 details

Have you been a surrogate before?

Have you applied to any other facilities and/or agencies as a surrogate?

If yes to previously being a surrogate, please give details

If yes to other surrogate applications, when did you apply and what is your current status?

Are you currently breastfeeding?

Have you ever placed a child for adoption?

If yes to breastfeeding, how often and when will you stop?

If yes to placing a child for adoption, please explain

Menstruation

Are your menstrual periods regular?

Yes No

Occasional bleeding between normal periods

Yes No

My period usually lasts 4-6 days

Yes No

Occasional bleeding after intercourse

Yes No

What form of birth control are you using?

Age when you got your first period

Do you have a regular monthly cycle?

Date of last pap smear

Please indicate the results of your last pap smear and provide details if abnormal or ever abnormal in the past. Last pap smear details

Number of children

Please provide the age, sex, and history of any health problems for each child (e.g., "Child #1: 13, male, asthma"): Description of children

Have you ever undergone fertility treatments to get pregnant?

Have you had any C-sections?

If yes to fertility treatments, please explain

If yes to C-sections, how many and what were the reasons

Multiple births

Willing to reduce multiple births

Intended Parents Preference

Anyone

Yes No

International intended parents

Yes No

Same sex intended parents

Yes No

Single intended parent (gay/lesbian)

Yes No

Domestic intended parents

Yes No

Heterosexual intended parents

Yes No

Single intended parent (heterosexual)

Yes No

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BASIC REQUIREMENTS

CONSENT

Menstruation

Intended Parents Preference