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
Are You Planning to Move Out of State in the Next 18 Months?* This field is required.
YESNO
5
Email Address* This field is required.
6
Phone Number* This field is required.
7
Best Days/Times to Reach You By Phone
8
Are You A US Citizen or Permanent Resident (Green Card Holder)?* This field is required.Currently, you MUST be a US Citizen or Green Card Holder to Qualify
US Citizen
Green Card Holder
Neither
9
Are You Currently Working with Any Other Agency?* This field is required.
YESNO
10
Height* This field is required.
11
Current Weight* This field is required.If you have a home scale, please provide your actual weight so we can calculate your BMI
12
Occupation* This field is required.
13
What is Your Net (After Taxes) Monthly Income?This number will be used to calculate potential expenses for intended parents
14
Do You Have Flexible Hours to Attend Appointments, or Can You Easily Request Time Off?Surrogacy requires attending appointments such as medical screening, monitoring during embryo transfer cycle, embryo transfer appointments, and appointments during pregnancy.
YESNO
15
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!
16
Marital Status* This field is required.Any sexual partners you have MUST also undergo medical screening
Married
Committed Partner
Single (not currently sexually active)
Single (currently sexually active with one or more casual partners)
17
If You Have a Partner, Please Provide Their NAME, DATE OF BIRTH and OCCUPATION
18
If Applicable, Is Your Partner Supportive of You Becoming a Surrogate?
YESNO
19
How Many Children Do You Have?* This field is required.
20
Do You Have Custody of Your Children?* This field is required.50/50 custody with an ex-partner is fine.
YESNO
21
Please Describe Your Support System* This field is required.Who provides emotional support, childcare when needed, help in emergencies?
22
Do You Have Health Insurance? If So, Which Policy?* This field is required.
23
Please Upload the Front of Your Insurance Card (skip if no insurance)Your insurance will be evaluated to see if it will cover surrogacy. If not, we will arrange for you to have health coverage during the pregnancy; however, surrogates with existing health insurance are in high demand!
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24
Please Upload the Back of Your Insurance Card (skip if no insurance)Your insurance will be evaluated to see if it will cover surrogacy. If not, we will arrange for you to have health coverage during the pregnancy; however, surrogates with existing health insurance are in high demand!
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Select files to upload
Max. file size: 10.6MB
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25
How Much is Your Monthly Insurance Premium?
26
Do You Have Any Health Conditions?* This field is required.If yes, please explain.
27
Are You Currently Taking Any Medications Besides Birth Control?* This field is required.If yes, please describe
28
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
29
Do You or Anyone in Your Home Smoke Tobacco Products/Vape?* This field is required.
YESNO
30
Do You or Anyone in Your Home Regularly Smoke or Otherwise Consume Marijuana?* This field is required.
YESNO
31
How Often Do You Consume Alcohol?* This field is required.
Daily
Weekly
Monthly
Rarely
Never
32
Please Describe Your Usual Diet* This field is required.
33
Do You Have Any Dietary Restrictions?* This field is required.
Vegetarian
Vegan
Keto
Paleo
Low Carb
Gluten Free
Organic
None
34
Have You Used Any Recreational Drugs in the Past 12 Months?* This field is required.If yes, please explain.
35
Do You Have Any History of Mental Illness?* This field is required.If yes, please explain
36
Have You Ever Been Prescribed Medication for Depression/Anxiety or Other Mental Health Disorders?* This field is required.If yes, please explain
37
Do You Have Any History of Prior Surgeries?* This field is required.
YESNO
38
If Yes, Please Describe the Surgery and When it Was Performed
39
Do You Have Any History of Sexually Transmitted Disease?* This field is required.
YESNO
40
If So, Please List Disease, Dates and If You Have Been Treated
41
Do You Have Any History of Peri- or Postpartum Depression?* This field is required.
YESNO
42
If Yes, Did This Diagnosis Require Medication?
43
Have You Been a Surrogate Previously?* This field is required.
YESNO
44
If Yes, Which Clinic/s Performed Your Embryo Transfer/s?
45
Have You Ever Been Diagnosed With:* This field is required.
Endometriosis
Bicornuate (Heart-Shaped) Uterus
Fibroids
Other Uterine Abnormality
PCOS
NONE
46
Have You Ever Experienced Any of the Following?* This field is required.Miscarriage, Abortion, Ectopic Pregnancy, Molar Pregnancy, Stillbirth
Miscarriage (No D&C/D&E)
Miscarriage (with D&C/D&E)
Elective Abortion (Surgical)
Elective Abortion (Medicated)
Ectopic Pregnancy
Molar Pregnancy
Stillbirth
None
Other
47
If So, When?
48
Did You Experience Any of the Following During Pregnancy* This field is required.Gestational Diabetes, Hypertension, Preeclampsia, Preterm Labor, Preterm Delivery, Placenta Previa, Placenta Accreta/Increta
Gestational Diabetes (Diet Controlled)
Gestational Diabetes (Medicated)
High Blood Pressure
Preeclampsia/Eclampsia
Preterm Labor (with preterm delivery)
Preterm Contractions (not resulting in preterm delivery)
Placenta Previa (which did not resolve on its own)
Placenta Previa (resolved on its own)
Placenta Accreta/Increta
None
49
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
50
Have You Been on Bedrest During Any of Your Pregnancies?* This field is required.
YESNO
51
If Yes, Please Explain The Reason and Duration
52
Please Provide the Date of Your Last Pap Smear, AND the Name of the Clinic or Doctor Who Performed It* This field is required.Please provide clinic info - we will need to request the result.
53
Are You Current on All Required Vaccines for Surrogacy (Measles, Rubella, Chickenpox, Hepatitis B)?* This field is required.If no and you test non-immune at screening, you will be required to obtain a booster shot to continue
54
If Not, Are You Willing to Update Your Boosters (Varicella, Rubella and Measles Immunity are REQUIRED for Surrogacy).* This field is required.
YESNO
55
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 & At Least One Booster
Yes - Vaccinated
No - Willing to Be Vaccinated if Necessary
No - Not Willing to Be Vaccinated
56
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.Most intended parents want to be able to make these decisions for their own child, unless the surrogate's life is in danger.
YESNO
57
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
58
Are You Open to Carrying Twins?* This field is required.
Yes - Open to Double Embryo Transfer
Yes - Only if Embryo Splits Naturally
No
59
Are You Open to Carrying for an Intended Parent Who Is a Carrier for Hepatitis B? (No risk to surrogate if she is vaccinated against Hep-B)
YESNO
60
Are You Open to Traveling for Screening/Transfer if Necessary? (All travel expenses would be covered)* This field is required.We currently work with many clinics nationwide, and occasionally internationally such as in Canada. If you do not have a passport, we will assist in obtaining one.
Yes - Open to Any Out of State or International Travel
Yes - Open to USA or Canadian Clinics
Yes - Open to Traveling Within the US Only
No
61
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
62
Will you allow the parents to attend appointments with you, if possible?* This field is required.
YESNO
63
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
64
What type of contact would you like with the intended parents after delivery of the baby?* This field is required.
65
Do you have any special requests from the Intended Parents during your pregnancy?* This field is required.
66
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
67
Please List Your Hobbies & Interests* This field is required.
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Do You Have Any Pets? If YES, Please List Number and Type
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Favorite Food* This field is required.
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Favorite Movie* This field is required.
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Favorite Book* This field is required.
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Favorite Music* This field is required.
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Favorite Vacation Destination* This field is required.
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What Are Your Dreams for the Future?* This field is required.
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Please Describe Any Concerns You May Have About a Surrogacy Journey So That Our Team Can Address Them With You!* This field is required.
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How Do You Plan to Utilize Your Surrogacy Compensation?* This field is required.There are no wrong answers!
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Do You Have Any Religious Affiliation?* This field is required.
Christian
Jewish
Christian (Catholic)
Muslim
Hindu
Sikh
Pagan/Wiccan
None
Other
78
Please Provide Your Pregnancy History* This field is required.You Must Have at Least ONE Prior Successful Pregnancy to Qualify
Delivery Date
Doctor/Clinic Name Who Provided Prenatal Care
Name/Location of Delivery Hospital
Number of Weeks' Gestation
Baby's Weight
Vaginal/C-Section
Own Baby/Surrogate
Pregnancy 1
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Pregnancy 2
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Pregnancy 3
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Pregnancy 4
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Pregnancy 5
Row 4, Column 0
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Pregnancy 6
Row 5, Column 0
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Row 5, Column 5
Row 5, Column 6
Pregnancy 1
Pregnancy 2
Pregnancy 3
Pregnancy 4
Pregnancy 5
Pregnancy 6
Delivery Date
Row 0, Column 0
Doctor/Clinic Name Who Provided Prenatal Care
Row 0, Column 1
Name/Location of 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 Name Who Provided Prenatal Care
Row 1, Column 1
Name/Location of 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 Name Who Provided Prenatal Care
Row 2, Column 1
Name/Location of 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 Name Who Provided Prenatal Care
Row 3, Column 1
Name/Location of 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 Name Who Provided Prenatal Care
Row 4, Column 1
Name/Location of 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 Name Who Provided Prenatal Care
Row 5, Column 1
Name/Location of 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 Introducing Yourself so the Intended Parents Can Get to Know You* This field is required.It's nice to share your daily life, lifestyle, family information, anything you would like to share!
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How Did You Hear About Us?
81
Please Upload a Copy of Your ID* This field is required.
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Please Upload 5-10 High-Quality Photos of Yourself and Your Family For Your Profile. It's A Great Idea to Have Someone Take Some Photos of Yourself and Your Family Outside, In Natural Light!* This field is required.Better photos mean a better overall profile!
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