Surrogate Application
Full Name
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Email
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Home Address
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Date of Birth
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Month
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Day
Year
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Cell Phone Number
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Have you been a Surrogate before?
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Please share a short bio about yourself. This is something that potential intended parents like to read to learn more about you, your life and your desire to become a surrogate.
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What is your residency status?
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What is your relationship status?
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Blood type? If you are unsure, answer N/A
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What is your Religion preference? If none, answer N/A
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What is your current height?
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What is your current weight?
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Do you currently have health insurance?
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Yes
No
If yes, What type of insurance?
Have you ever been charged with a misdemeanor or felony?
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Yes
No
If yes, please explain:
Are you Covid Vaccinated?
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What is your form of Birth Control? (Pills, Condoms, IUD, etc.)
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What is your diet like? Please, describe. (Ex: regular, keto, vegan vegetarian, etc.)
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Do you have any allergies? (Environmental or food)
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Environmental
Food
None of the above
How would you describe your everyday life?
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How would you describe your personality and character?
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What are your interests, hobbies and talents?
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Do you have any pets?
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Yes
No
Do you have reliable transportation?
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Yes
No
Will you require childcare in order to attend appointments associated with Surrogacy?
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Yes
No
Partner's Full Name
Partner's Age
Partner's Occupation
Length of relationship?
Partner's criminal history?
Please list any additional people living in your home: including name, age, and relationship. Ex: Heather, 3years old, daughter
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Do you or your partner currently smoke?
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Yes, I smoke.
Yes, my partner smokes.
No, Neither of us smoke.
Does anyone living with you smoke?
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Yes
No
Are you or your partner taking any prescriptions?
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Yes, I am taking medication.
Yes, My partner is taking medication.
No, Neither of us are taking medication.
Have you or your partner taken any anti-depressants, anti-psychotics or anti-anxiety medication in the last six (6) months?
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Yes
No
Who is your current Employer?
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What is your current Job title?
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How many hours do you work per week?
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Please, describe your job duties
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Is your employer supportive of your decision to become a Surrogate?
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Yes
No
What is your Highest level of Education?
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Describe your future goals?
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How many pregnancies have you carried to delivery?
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Have you had any miscarriages or abortions? If yes, please share how far along in your pregnancy you were and what year.
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How many biological children do you have?
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Did you have any complications during your pregnancies?
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Yes
No
Did you delivery any of your pregnancies prior to 36 weeks gestation?
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Yes
No
Please share the following for each of your pregnancies: Month/Delivery year, Weeks of pregnancy at deliver, Gender, and Weight (EX: February 2012, 38 weeks, Female, 7lbs 8oz)
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Have you had more than 2 c-sections?
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Yes
No
Do you exercise? If yes, how often?
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Do you have regular monthly periods?
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Yes
No
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Are you currently breastfeeding?
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Yes
No
Have you had any unsuccessful attempts to conceive a child?
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Yes
No
Have you had any surgeries?
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Yes
No
When was your last pap smear?
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Have you had any abnormal Pap smears?
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Yes
No
Are you currently sexually active?
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Yes
No
How many partners have you had in the last year?
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Have you ever had a HIV screening completed?
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Yes
No
Have you ever completed Hepatitis B Immunization?
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Yes
No
Have you received any tattoos or piercings in the last 12 months?
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Yes
No
Have you or your partner ever seen a psychologist, psychiatrist or counselor?
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Yes
No
Have you or your partner attempted or committed suicide?
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Yes
No
Have you or your partner had any mental disorders?
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Yes
No
Have you or your partner had any anxiety, learning disabilities?
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Yes
No
Have you had any ADHD?
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Yes
No
Have you ever been diagnosed with out of normal range TSH levels (indicating Thyroid issues)?
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Yes
No
Are your TSH levels (thyroid function) currently within normal range without medications?
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Yes
No
Any nicotine or drugs in your system are strictly forbidden during a surrogacy cycle. Are you willing to be nicotine and drug screened (including narcotics, marijuana, anti-anxiety medications, and anti-depressant medications) before and during your surrogacy cycle?
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Yes
No
Is your partner / spouse willing to get drug screened?
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Yes
No
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Have you ever been a surrogate before?
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Yes
No
Why do you want to be a Surrogate?
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The clinic the IPs you could be matched with might request an OB Clearance form. Are you willing to get this form filled out, we will email it to you
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Yes
No
Are you currently working with another agency?
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Yes
No
Can you please describe the support system you have for your surrogacy journey?
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Who will watch your kids while you attend appointments associated with surrogacy such as Medical Screening, Embryo Transfer, and Delivery?
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Who will be your companion when you are further along in your Surrogacy pregnancy?
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Who will drive you to the Hospital, when you are in labor?
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Describe what type of relationship you would like to have with the Intended Parents before, during and after the pregnancy:
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During your Surrogacy journey you will be expected to take a course of medications, some including injections. Are you comfortable with giving yourself injections or have someone to help administer them for you?
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Yes
No
Would you be willing to breast pump after delivery?
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Yes
No
Would you be willing to carry Twins?
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Would you be willing to carry Twins if the ONE embryo split or via 2 Embryo transfer?
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Would you terminate pregnancy if medically advised to due to health risk to you and/or the baby?
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Yes
No
Are you willing to terminate the pregnancy if the fetus has a disease?
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Yes
No
Would you terminate the pregnancy at the parent’s request if developmental abnormalities are detected (Down syndrome, chromosomal abnormalities, absence of a limb or limbs):
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Yes
No
Would you be willing to reduce Triplets to Twins if advised by a doctor and the intended parents?
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Yes
No
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Would you be willing to serve as a surrogate for a family of a different race, religion or ethnic background from your own?
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Yes
No
Would you be willing to work with IPs with HIV positive or Hepatitis B?
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Yes
No
What reassurance can you give the Intended Parents that you will not change your mind about relinquishing the baby/Babies?
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Would you like the intended parents to tell their child about you?
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Yes
No
How is your living environment? (ex: loud, calm, relaxing, hectic, etc)
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Are you willing to get the Covid vaccine if requested by the intended parent's physician?
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Yes
No
How far is the nearest Hospital to you with NICU?
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If you are an experienced Surrogate, How many transfers did each journey need to result in a successful pregnancy?
How would you feel If the child requested to meet you in the future?
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Is there anything else that we haven’t discussed that you’d like to share to stand out from other surrogates?
What message would you like to convey to the intended parents?
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Disclosure:
By providing your phone number you consent to receive text messages from Serene Surrogacy Partners regarding your inquiry to become a Gestational Carrier. Message frequency will vary. Message and data rates may apply. For assistance, reply HELP or contact contact@serenesurrogacypartners.com. To stop receiving messages, reply STOP. No further messages will be sent. For details, see our Privacy Policy https://www.serenesurrogacypartners.com/privacy-policy
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