Dreamweaver Surrogacy Application

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Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Email Address* This field is required.
5
Phone Number* This field is required.
6
Best Days/Times to Reach You By Phone
7
Height* This field is required.
8
Current Weight* This field is required.
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Occupation* This field is required.
10
Do You Have a Stable Home Situation?* This field is required.Renting, owning, living with family are all acceptable. We just need to know you're safe in one place for the duration of the surrogacy!
11
Marital Status* This field is required.
Married
Committed Partner
Single (not currently sexually active)
Single (currently sexually active with more than one partner)
12
If You Have a Partner, Please Provide Their NAME, DATE OF BIRTH and OCCUPATION
13
How Many Children Do You Have?* This field is required.
14
Do You Have Custody of Your Children?* This field is required.50/50 custody with an ex-partner is fine.
YESNO
15
Please Describe Your Support System* This field is required.Who provides emotional support, childcare when needed, help in emergencies?
16
Do You Have Health Insurance? If So, Which Policy?* This field is required.
17
Do You Have Any Health Conditions?* This field is required.If yes, please explain.
18
Are You Currently Taking Any Medications Besides Birth Control?* This field is required.If yes, please describe
19
Which Birth Control Method Do You Currently Use?* This field is required.
Pill
Patch
IUD (hormonal)
IUD (copper)
Nexplanon Implant
NuvaRing
Tubal Ligation
Condom
Other
None
20
Do You Smoke?
YESNO
21
How Often Do You Consume Alcohol?
Daily
Weekly
Monthly
Rarely
Never
22
Have You Used Any Recreational Drugs in the Past 12 Months?* This field is required.If yes, please explain.
23
Do You Have Any History of Mental Illness?If yes, please explain
24
Do You Have Any History of Prior Surgeries?* This field is required.
YESNO
25
If Yes, Please Describe the Surgery and When it Was Performed
26
Do You Have Any History of Sexually Transmitted Disease?* This field is required.
YESNO
27
If So, Please List Disease, Dates and If You Have Been Treated
28
Do You Have Any History of Peri- or Postpartum Depression?* This field is required.
YESNO
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Have You Been a Surrogate Previously?* This field is required.
YESNO
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Have You Ever Had Any of the Following?* This field is required.
Miscarriage
Abortion
Ectopic Pregnancy
Molar Pregnancy
None
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If So, When?
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Did You Experience Any of the Following During Pregnancy* This field is required.
Gestational Diabetes
High Blood Pressure
Preeclampsia/Eclampsia
Preterm Labor (with preterm delivery)
Preterm Labor (not resulting in preterm delivery)
Placenta Previa (which did not resolve on its own)
None
33
Have You Undergone Any Fertility Treatment in the Past, Including Previous Surrogacy or Egg Donation Cycles?* This field is required.Select all that apply
Previous Surrogate
Previous Egg Donor
Previous Surrogacy Attempts (not resulting in pregnancy, or resulting in miscarriage)
IVF/IUI to Conceive Own Children
None
34
Have You Been on Bedrest During Any of Your Pregnancies?* This field is required.
YESNO
35
WHEN and WHERE (clinic or doctor name) Was Your Last PAP SMEAR?* This field is required.Please provide clinic info - we will need to request the result.
36
Are You Current on All Required Vaccines for Surrogacy (Measles, Rubella, Chickenpox, Hepatitis B)?* This field is required.
37
Are You Vaccinated for COVID-19* This field is required.Some fertility clinics require vaccination. This information will help us in finding you a suitable match. Vaccination is not required to become a surrogate, although it will make matching easier.
Yes - Fully Vaccinated
Yes - Partially Vaccinated
No - Willing to Be Vaccinated if Necessary
No - Not Willing to Be Vaccinated
38
Are You Open to Terminating the Pregnancy at the Parents' Request And Doctor's Recommendation for Serious Medical Issues, Down Syndrome, Surrogate's Life in Danger etc.?* This field is required.
YESNO
39
If a Multiple Pregnancy Beyond Twins is Confirmed, Are You Open to Selective Reduction if Doctor Recommends?* This field is required.Selective reduction means aborting a fetus to maintain the health of the other fetus(es) or the gestational carrier
YESNO
40
Are You Open to Carrying Twins?* This field is required.
Yes - Open to Double Embryo Transfer
Yes - Only if Embryo Splits
No
41
Are You Open to Carrying for a Parent Who Is a Carrier for Hepatitis B? (No risk to surrogate if she is vaccinated against Hep-B)
YESNO
42
Are You Open to Traveling for Screening/Transfer if Necessary? (All travel expenses would be covered)We currently work with many clinics nationwide, and occasionally internationally.
Yes - Open to Out of State or International Travel
Yes - Open to Out of State Only
No
43
Do you agree to keep the agency and the parents informed of all doctor's appointments, and to provide us with visit summaries/ultrasound images?* This field is required.
YESNO
44
Will you allow the parents to attend appointments with you, if possible?* This field is required.
YESNO
45
Will you allow the parents in the delivery room at the birth of their child, if it is their wish to be present?* This field is required.
YESNO
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What type of contact would you like with the intended parents after delivery of the baby?* This field is required.
47
Do you have any special requests from the IPs during your pregnancy?* This field is required.
48
Are You Open to Working With...* This field is required.Select all that apply
Heterosexual Couples
Same-Sex Couples
Single Mothers
Single Fathers
International Families
Families of Another Race Than Yourself
49
Please List Your Hobbies & Interests* This field is required.
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Do You Have Any Religious Affiliation?
Christian
Jewish
Christian (Catholic)
Muslim
Hindu
Sikh
Pagan/Wiccan
None
Other
51
Please Provide Your Pregnancy History* This field is required.
Delivery Date
Doctor/Clinic Who Provided Prenatal Care
Delivery Hospital
Number of Weeks' Gestation
Baby's Weight
Vaginal/C-Section
Own Baby/Surrogate
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Pregnancy 2
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Pregnancy 3
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Pregnancy 4
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Pregnancy 5
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Pregnancy 6
Row 5, Column 0
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Pregnancy 1
Pregnancy 2
Pregnancy 3
Pregnancy 4
Pregnancy 5
Pregnancy 6
Delivery Date
Row 0, Column 0
Doctor/Clinic Who Provided Prenatal Care
Row 0, Column 1
Delivery Hospital
Row 0, Column 2
Number of Weeks' Gestation
Row 0, Column 3
Baby's Weight
Row 0, Column 4
Vaginal/C-Section
Row 0, Column 5
Own Baby/Surrogate
Row 0, Column 6
Delivery Date
Row 1, Column 0
Doctor/Clinic Who Provided Prenatal Care
Row 1, Column 1
Delivery Hospital
Row 1, Column 2
Number of Weeks' Gestation
Row 1, Column 3
Baby's Weight
Row 1, Column 4
Vaginal/C-Section
Row 1, Column 5
Own Baby/Surrogate
Row 1, Column 6
Delivery Date
Row 2, Column 0
Doctor/Clinic Who Provided Prenatal Care
Row 2, Column 1
Delivery Hospital
Row 2, Column 2
Number of Weeks' Gestation
Row 2, Column 3
Baby's Weight
Row 2, Column 4
Vaginal/C-Section
Row 2, Column 5
Own Baby/Surrogate
Row 2, Column 6
Delivery Date
Row 3, Column 0
Doctor/Clinic Who Provided Prenatal Care
Row 3, Column 1
Delivery Hospital
Row 3, Column 2
Number of Weeks' Gestation
Row 3, Column 3
Baby's Weight
Row 3, Column 4
Vaginal/C-Section
Row 3, Column 5
Own Baby/Surrogate
Row 3, Column 6
Delivery Date
Row 4, Column 0
Doctor/Clinic Who Provided Prenatal Care
Row 4, Column 1
Delivery Hospital
Row 4, Column 2
Number of Weeks' Gestation
Row 4, Column 3
Baby's Weight
Row 4, Column 4
Vaginal/C-Section
Row 4, Column 5
Own Baby/Surrogate
Row 4, Column 6
Delivery Date
Row 5, Column 0
Doctor/Clinic Who Provided Prenatal Care
Row 5, Column 1
Delivery Hospital
Row 5, Column 2
Number of Weeks' Gestation
Row 5, Column 3
Baby's Weight
Row 5, Column 4
Vaginal/C-Section
Row 5, Column 5
Own Baby/Surrogate
Row 5, Column 6
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Please Write a Short Note About Yourself so the Intended Parents Can Get to Know You* This field is required.
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How Did You Hear About Us?
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Please Upload a Copy of Your ID* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Please Upload Some High-Quality Photos of Yourself and Your Family For Your Profile (these will be shared with intended parents, so the higher quality the better! Intended parents like a mix of shots of just you, and pictures of you "being a mom").* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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