Form
Tiny Treasures Advocacy Application - Brenda
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you ever gone by any other last name? If so what last name(s)
Date of Birth
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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My height is
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. My weight is
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.
My occupation is
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.
Do you have a stable home life?
Yes
No
Marital Status
Single (not sexually active)
Married
Committed Partner
Single (sexually active with multiple people)
If you have a partner please list THEIR NAME, DATE OF BIRTH, AND OCCUPATION
Partner's email
example@example.com
Partner's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How many children do you have?
Do you have custody of your children?
Yes
No
How did you hear about our agency / who referred you?
Please describe your support system.
Do you have health insurance? If so what policy?
Do you have any health conditions? If so what conditions?
Are you currently taking any medication besides birth control?
Which birth control method do you use?
None
Condoms
Pill
IUD (hormonal)
Nexplanon Implant
Tubal Ligation
Patch
IUD (copper)
Nuvaring
Other
Do you smoke?
Yes
No
How often do you consume alcohol?
Daily
Weekly
Monthly
Rarely
Never
Have you used any recreational drugs in the past 12 months? If so which drugs?
Are you menstrual cycles normal and consistent?
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Do you have ANY history of mental illness? If so what mental illness?
Are you a US citizen? If not, do you hold a Green Card?
Do you have a REAL ID (new TSA requirement to fly)
Are you currently nursing or pumping?
Yes
No
Have you been a surrogate before?
Yes
No
Have you had any of the following?
Miscarriage
Ectopic Pregnancy
Abortion
Molar Pregnancy
None
If you answered yes to any of the above, please list the year and week pregnant that the occurrence took place.
Did you experience ANY of the following in pregnancy?
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
If you selected yes to any of the above, please give an explanation.
Have you undergone any fertility treatment in the past, including previous surrogacies or egg donation cycles?
Previous surrogate
Previous egg donor
Previous surrogacy attempts (not resulting in pregnancy or miscarriage)
IVF/IUI to conceive own children
None
Have you been on bed rest for any of your pregnancies?
Yes
No
When and where was your last Pap Smear?
When and where was your last annual exam (physical)?
Are you current on ALL required vaccines for surrogacy? (Measles, Rubella, Chickenpox, Hepatitis B)
Are you vaccinated for Covid 19?
Yes - fully vaccinated
Yes - partially vaccinated
No - willing to be vaccinated if necessary
No - not willing to get vaccinated
Are you open to terminating the pregnancy at the parents' request and doctors' recommendation for serious medical issues, to include down syndrome, or if your life is in danger?
Yes
No
If multiple pregnancies beyond twins is confirmed are you open to selective reduction?
Yes
No
How many embryos are you open to transferring at a time? We only allow single embryo transfers unless embryo quality is very low.
Single
Double
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Are you open to traveling for screening/embryo transfer if necessary? (all expenses are paid for)
Yes
No
Do you agree to keep the agency and the parents informed on all appointments and provide all ultrasound imaging to both parties?
Yes
No
Will you allow parents to attend appointments with you?
Yes
No
Will you allow the parents to be in the room during delivery?
Yes
No
What does your typical diet consist of?
Are you open to working with:
Heterosexual Couples
Same sex couples
Single mothers
Single fathers
International families (you would never travel internationally)
Families of another race than you
Transgender individuals
Do you have any religious affiliations? If so what?
Please provide ALL prior pregnancy information.
Rows
Date of Delivery
Numbers of weeks delivered at
Hospital name, address and phone number
OB name, address and phone number
Birth weight
Vaginal Or C-Section
Pregnancy 1
Pregnancy 2
Pregnancy 3
Pregnancy 4
Pregnancy 5
Please upload 5-7 high quality photos of yourself and some with your family for intended parents to see.
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