Prerequisite Approval Form (Surrogate)
This form provides Wishful Miracles with the ability to pre-approve your submission and move forward with your surrogacy journey. Please fill out the following information. A Wishful Miracles consultant will then send you Medical Release.
Name
*
First Name
Middle Name
Last Name
Maiden Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Height
*
Weight
*
Are you working?
*
Please Select
Yes
No
Do you have a stable income and living situation?
*
Please Select
Yes
No
Please list everyone living in your household and their relationship to you:
Do you smoke?
*
Please Select
Yes
No
How many pregnancies have you had? (please note you must have given birth at least once to become a surrogate)
*
How many miscarriages have you had?
*
If none please put N/A
How many abortions have you had?
*
If none please put N/A
Have you had any complication with any of your pregnancies?
*
Please Select
Yes
No
If yes, please explain:
*
Did you have a vaginal birth or C-section? Please explain.
*
Describe health issues with any/all of your children?
*
Why do you want to become a surrogate?
*
Are you willing to exclusively work with Wishful Miracles Inc. for a minimum of 90 days?
*
Please Select
Yes
No
Submit
Should be Empty: