Acorn Surrogacy Center (ASC)
Surrogate Application
Begin Application
*
Personal Information
1. Basic Compensation Preference
*
$35,000-$65,000, depending on experience
2. Full Name
*
First Name
Middle Name
Last Name
3. Age
*
4. Height
*
5. Weight
*
6. City, State, Country
*
7a. Occupation
*
7b. Current medical insurance
*
8. Marital status
*
9. Repeat surrogate?
*
Yes
No
Back
Next
Save
10a. Spouse/partner name
First Name
Last Name
10b. Spouse/partner occupation
11a. Ethnicity
*
11b. Race/National origin
12. Parent's Ancestry
*
Ethnicity
Mother's ethnicity
Mother's national origin
Father's ethnicity
Father's national origin
13. Children
*
14. Religion at birth
15. Practicing religion
16a. Have you received any tattoos in the last year?
*
Yes
No
16b. Number of tattoos and date of last tattoo?
*
17a. Have you received any piercings in the last year?
*
Yes
No
17b. Number of piercings and date of last piercing?
*
18. Other distinguishing features
19. Date of Marriage:
/
Month
/
Day
Year
Date
Back
Next
Save
20-26. Have you or your husband/partner ever:
Yes
No
If Yes, Please explain
20. Filed for bankruptcy?
21. Been in a psychiatric facility?
22. Been arrested?
23. Been involved in any legal cases, or any that are pending?
24. Been in a substance abuse program?
25. Do you drive?
26. Do you own a car or have reliable transportation?
Back
Next
Save
Medical/ Genetic Information
27. Were you adopted?
Yes
No
If so, do you have information about your biological parents?
Were you adopted?
28. Blood type:
*
A+
B+
AB+
O+
A-
B-
AB-
O-
Unknown
29. Sexual Orientation:
*
30. Numbers of pregnancies:
*
31. Date of last OBGYN visit:
32. Date of last Pap Smear:
33. Result of last Pap Smear:
Normal
Abnormal
Other
34-37. please select and explain
*
Yes
No
If so, please explain
34. Has your weight changed dramatically in the last five years for reasons other than pregnancy?
35. Are you using birth control?
36. Do yo have regular monthly menstrual cycles?
37. Are there twins or triplets in your family
38-45. Please select and explain
*
Yes
No
If so, Please explain
38. Do you smoke?
39. Do you drink any alcoholic beverages?
40. Have you ever used illicit drugs?
41. Are you currently using illicit drugs?
42
Are you currently sexually active with anyone other than your partner listed on this application?
43. Have you ever been physically abused?
44. Have you ever sexually abused?
45.
Have you ever had thoughts or attempted suiside?
46. Please list any medications and dosages you are currently taking:
*
47. Please list any hospitalizations, surgeries, or plastic surgeries you have had and the dates each event occurred:
*
48. Have you or your husband or partner or any other sexual partners ever been diagnosed with
*
Yes
No
If yes, who
HIV
Chlamydia
Syphilis
Gonorrhea
HPV
Genital Herpes
Hepatitis B
Hepatitis C
Ovarian Cyst
PID
Back
Next
Save
Education/Employment
49. Current employment position:
*
50. What were your best subjection in school?
*
51. Highest level of school completed:
*
Middle school
High school
Some college
Bachelor Degree
Master Degree
Doctorate Degree
52. Do you have plans on furthering your education?
Characteristics
53. Please describe your personality and character:
*
54. What are your hobbies, interests and talents?
*
55. What do you like to do in your spare time?
*
56. What are your goals in life?
*
57. What is the reason for you to be a surrogate mother?
*
58. Briefly explain your understanding about how the surrogacy program works?
*
59. What would you consider most important in choosing a Recipient Couple?
*
60. What relationship do you want to have with the intended parents during conception and pregnancy?
*
61. Would you like to meet the Recipient couple?
*
62. What is the maximum number of embryos you are willing to have transferred at each appointment?
*
One embryo
Two embryos
Other
63. Are you willing to carry:
*
Singleton
Twins
Triplets
Other
64. Would you undergo a selective reduction procedure if a multiple pregnancy is confirmed?
*
Yes
No
65. If there is a medical problem with the pregnancy, or with the child you are carrying as a surrogate and the intended parents want to consider abortion, would you allow them to make that decision based on the advice of their physician and personal beliefs?
*
66. Do you and your husband/partner understand that, unless you have had a tubal ligation or your husband/partner has had a vasectomy, you must agree to abstain from sexual activity while undergoing medical treatment and participating in this program?
*
Yes
No
Your Email address:
example@example.com
I swear or affirm that the above and foregoing representations are true and correct to the best of my information, knowledge, and belief.
*
Please sign and date above the line
Date
-
Month
-
Day
Year
Date
Please upload 1-2 Happy, Family style photos of yours to complete your application
Please verify that you are human
*
Save
Submit
Clear Form
Print Form
Should be Empty: