SURROGATE APPLICATION


Section 1 of 6: Personal Information
About 4 Minutes

NAME Phone Number* Email* Address* 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

Section 2 of 6: Requirements & Consent
About 3 Minutes

Basic Requirements

I am a female non-smoker age 21-35 YesNo
Were your pregnancies complicated? YesNo
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 YesNo
I am a citizen of the United States YesNo
I have a reliable car with insurance YesNo
Do you have any ongoing legal disputes? YesNo
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. YesNo
Does anyone living in your home, including yourself, smoke, abuse alcohol, or use recreational drugs? YesNo
Have you received any psychiatric care in the last ten years? YesNo
I reside in the state of California YesNo
Are you receiving any federal or state financial assistance? YesNo

Consent

I agree to meet with a licensed mental health professional for a psychological exam YesNo
I understand a background check for myself and my husband/partner will be performed YesNo
I understand that my BMI must be 18 to 29 * YesNo
I am willing for a staff member to conduct a home visit YesNo
I will allow a full medical examination which will include a vaginal ultrasound, pelvic examination, disease testing, and drug testing YesNo

Section 3 of 6: Lifestyle
About 3 Minutes

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
Your Occupation 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

Section 4 of 6: Reproductive History
About 8 Minutes

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 #3 details Have you been a surrogate before? If yes to previously being a surrogate, please give details Are you currently breastfeeding? If yes to breastfeeding, how often and when will you stop?
Pregnancy #2 details Pregnancy #4 details Have you applied to any other facilities and/or agencies as a surrogate? If yes to other surrogate applications, when did you apply and what is your current status? Have you ever placed a child for adoption? If yes to placing a child for adoption, please explain

Menstruation

Are your menstrual periods regular? YesNo Occasional bleeding between normal periods YesNo My period usually lasts 4-6 days YesNo
Occasional bleeding after intercourse YesNo
What form of birth control are you using? Do you have a regular monthly cycle? Please indicate the results of your last pap smear and provide details if abnormal or ever abnormal in the past. Last pap smear details
Age when you got your first period Date of last pap smear

Section 5 of 6: Your Children
About 4 Minutes

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? If yes to fertility treatments, please explain
Have you had any C-sections? If yes to C-sections, how many and what were the reasons

Section 6 of 6: Personal Preferences
About 3 Minutes

Multiple births
Willing to reduce multiple births

Intended parents preference

Anyone YesNo International intended parents YesNo Same sex intended parents YesNo Single intended parent (gay/lesbian) YesNo
Domestic intended parents YesNo Heterosexual intended parents YesNo Single intended parent (heterosexual) YesNo