Name
*
First Name
Last Name
Email
*
Phone
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your BMI
*
Age
*
Are you a U.S. Citizen?
*
Yes
No
Do you have any children?
*
Yes
No
Age of child(ren)
*
How many C Sections have you had?
*
Have you had complications during your prior deliveries or pregnancies?
*
Yes
No
Do you smoke or vape?
*
Yes
No
Were all your births full term (live births at 37 weeks or above)?
*
Yes
No
Have you had any miscarriages? If yes, please write the year(s) & how far along you were.
*
Have you had any abortions? If yes, please write the year(s).
*
Are you currently on birth control? If yes, please specify what type (pill, IUD, arm implant, depo shot, etc)
*
Are you currently taking any prescription medications? If yes, please share what it is & why you are taking it.
*
Have you been a surrogate before?
*
Yes
No
Questions or comments?
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