Surrogate/Carrier Application
Please complete this form to the best of your ability. We will contact you shortly after submission.
Name:
*
First Name
Last Name
E-mail:
*
example@example.com
Re-type E-mail:
*
example@example.com
What's your phone number?
*
When is the best time to contact you?
*
What is the best way for us to reach you?
*
Phone
Text
Email
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
*
Google search
Facebook group/ad
Another surrogate
Word of mouth
Other
What is your State of residence?
*
Birth Date
*
How old are you?
*
Are you a United States Citizen or Permanent Resident?
*
Yes
No
What is your Ethnicity (mark as many as applicable):
*
Hispanic/Latino
African American
Caucasian
Indian (non Native American)
Native American/Alaskan Native
Pacific Islander
Middle Eastern
Asian
Other
Have you, or anyone in your household, ever been arrested or convicted of a crime? If yes, please explain:
*
Do you currently use tobacco products (cigarettes, e-cigarettes, etc?)
*
No
Yes
Do you use marijuana products that contain THC (smoke joints, vape, edibles, etc?)
*
No
Yes
Are you a previous smoker?
*
No
Yes
Have you been a gestational surrogate before?
*
Yes
No
Congrats! Please tell us about your experience:
Have you ever been denied by another surrogacy agency?
*
Yes
No
Please tell us about the circumstances. What were the reasons?
Please tell us why you want to be a surrogate?
*
Health Information
How many vaginal births have you had?
*
Please Select
0
1
2
3
4
5
6+
How many C-sections have you had?
*
Please Select
0
1
2
3
4+
Please list the dates of live births, as well as how many weeks along you were at delivery?:
*
Have you had any miscarriages?
*
Yes
No
If yes, please explain.
Are you willing to terminate a pregnancy if the fetus has abnormalities and the intended parent(s) ask you to? You will never be asked to terminate a healthy pregnancy.
*
Yes
No
Undecided
If "undecided" please explain:
Have you experienced any of the following? Please mark all that apply.
*
Pre-Eclampsia
High Blood Pressure
Pre-term delivery (prior to 37 weeks gestation)
Fetal Growth Restriction
HSV Positive (herpes symplex virus)
Bed rest for singleton pregnancy
PIH (pregnancy induced hypertension)
Hyperthyroidism
Gestational Diabetes - controlled by diet
Gestational Diabetes - prescribed medication
None of the Above
Please mark all that apply:
*
Abnormal pap smear
HIV Diagnosis
Hepatitis B
Untreated Hepatitis C
Bi-Polar disorder
3 or more C-Sections
Criminal history
Gastric bypass surgery
A body piercing or tatoo in the last 6 months?
Taking medication for Depression
5 or more total deliveries
Had your tubes tied (Adiana or Essure procedure)
Taking medication for anxiety
Drug addiction and/or rehab
Post-partum depression
Consumed tobacco/marijuana products in the last 6 months
Prior smoker
None of the above
Please give the approximate month/year of your last pap smear:
*
What is your height?
*
What is your weight?
*
We use this to calculate your Body Mass Index. It must be under 34 to qualify.
Are you willing to administer self injectable medications?
*
Yes
No
Are you vaccinated against COVID 19?
*
Yes
No
Are you willing to get the booster if the IP(s) clinic requests it?
*
Yes
No
Unsure
Are you willing to receive the vaccination in order to be matched?
*
Yes
No
Unsure
Partner Information
Do you have a partner or spouse residing with you who is joining you on your surrogacy contract?
*
Yes
No
It's complicated
Name of partner/spouse:
*
First Name
Last Name
Phone Number of Partner/Spouse
*
-
Area Code
Phone Number
Email of Partner/Spouse
example@example.com
Who do you currently live with? Mark all that apply:
*
Partner/spouse
Child/ren
Your parent(s)
Roommates
I live alone
Other
What type of birth control are you using to prevent pregnancy?
*
Education and Occupation
Are you currently a student?
*
Yes
No
Highest level of education?
*
High School
Some college
Bachelor's Degree
Master's Degree
PhD.
Technical/trade school
Cosmetology/beauty
Other
Are you currently employed?
*
Yes
No
Where do you work?
What is your job title?
How many hours per week do you work?
What is your hourly wage? If salary, how much per pay period?
Are you currently receiving any form of public assistance (food stamps, Medicaid, welfare, housing assistance,etc)?
*
No
Yes
Do you have health insurance?
*
Yes
No
What is the name of your insurance carrier?
*
Do you know if you can use it for a surrogate pregnancy?
*
Please upload a copy of your insurance card here:
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Upload a copy of your most recent paystub here:
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Matching Preferences
What type of family do you want to carry for?
*
Are you able and willing to travel?
*
Are you willing to carry twins?
*
Yes
No
If no, are you willing to carry twins if the embryo splits in utero?
Yes
No
Clinics typically only allow one embryo transfer per cycle.
Are you willing to selectively reduce?
*
Yes
No
I don't understand what selective reduction is.
Only applicable if the embryo splits.
Do you have a valid driver's license?
*
Yes
No
If yes, please upload a copy of your driver's license below:
Upload copy of your driver's license here:
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Do you have reliable transportation?
*
Yes
No
Please upload three photos that will be used on your matching profile.
These should be photos you would feel comfortable using on a job application, use natural light, have no face altering filters, wear modest clothing.
A photo of yourself.
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A photo of you and your children.
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A photo of you and your partner (with your child/ren is fine), or someone who is of great support to you during this journey.
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A photo just for fun if you have too many and can't decide.
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Digital Signature
By typing your name below, you acknowledge that you are signing this document electronically.
Digital Signature:
*
Date:
*
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