Surrogate Application Form(Official)
Personal Info
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First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Height
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Weight
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Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Home Address
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City
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State
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Zip Code
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Have you received Covid vaccine in the past?
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Yes
No
If Yes,When?
If No,are you willing to receive Covid Vaccine?
Yes
No
Have you received any tattoos in the past year? Please list Date of your last tattoo
Yes
No
Do you have any religions?(If Yes,please specify your religion)
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1.Are you a US citizen or permanent resident?
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Yes
No
2.What is your race
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3.Sexual Orientation
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4.Marital status(eg:married/single/committed relationship/divorced)if married, please list date of marriage
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5.How many biological children do you have?
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6.What languages do you speak fluently?
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7.Is your schedule flexible? You might be required to attend to more than one medical appointment per week.
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Yes
No
8.Do you have a valid driver’s license?
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Yes
No
9.Do you have reliable transportation?
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Yes
No
10.Do you have car insurance?
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Yes
No
11.What is the name of your health insurance carrier?
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12. Have you been arrested? If yes,please explain
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13. Have you been involved in ANY legal cases, or any that are pending?
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14. Do you currently receive any forms of government assistance (e.g. Cash Aid/TANF/Food stamps/Medicaid/Section 8/etc.)?
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15. Do you have any travel or relocation plans within the next two years?
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If yes, please provide details about when and where you plan to travel or relocate.
Education/Employment
1.What is the highest-level education you have completed?
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2.Do you have plans on furthering your education?
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3.Are you currently employed?
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Yes
No
4.Who is your present employer? What is your title/position?(eg:please put N/A if no)
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5.How long have you been employed?(eg:please put N/A if no)
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Pregnancy Info:
1.List of pregnancies
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Rows
own/surrogacy
#baby delivered
delivered date
Vaginal/C-section
gender
weight(lbs&oz)
weeks at birth
complications
1
2
3
4
5
6
2.Have you ever had an abortion?
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Yes
No
If Yes,please specify when:
Have you ever had a miscarriage?
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Yes
No
If Yes,please specify when:
4.Have you ever experienced the following conditions?
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Rows
NO
YES
If Yes ,please explain
None
Gestational Diabetes
Hypertension
Toxemia
Placenta Previa
Pre-Eclampsia
Placenta Abruption
Post-partum depression
Pre-term labor
Short cervix
Bedrest
5.Are you currently breastfeeding?
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Yes
No
If Yes,When plan to stop
6.Are you sexually active?
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Yes
No
7.Are you using birth control?
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Yes
No
If Yes,What kind(eg:birth control pills/IUD)
8.Do you have regular monthly menstrual cycles?
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Yes
No
If No,please specify
9.When did you last see your Ob/Gyn?
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10.What is the date of your last Pap Smear? What is the result?
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11.Please list any reproductive illness you have ever experienced.(Please put N/A if no)
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Family Support:
1.Do you have a spouse or significant other?
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Yes
No
1.a Your spouse or significant other occupation
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2.Does your family support your decision to become a Gestational Carrier?
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Yes
No
3.Who would help if you were ordered to be on bed rest for a period of time?
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4.Do you anticipate any difficulties in becoming a surrogate?(eg:NO/YES,please explain)
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5.Describe your current living conditions.
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6.Please list everyone living in your household including ages and relationship.
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Rows
name
age
relationship
1
2
3
4
5
6
7.Do you have any pets at home?(eg:No/Yes,please specify)
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Medical Info（Continued）
1.Your Blood type?
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A
B
O
AB
Unsure
2.What is your Rh factor?
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Positive
Negative
Unsure
3. Weight
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4Height
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5.Do you drink alcoholic beverages?(eg:No/If Yes,please specify)
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6.Do you or anyone in your household smoke?(eg:No/if Yes,please specify)
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7.Do you or anyone in your household use illicit drugs?(eg:No/if Yes,please specify)
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8.Have you had any form of Tobacco, Marijuana, or any form of illicit drugs within past6 months?(eg:No/if Yes,please specify)
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9.Are you taking any medication?(eg:No/if Yes,please specify)
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10.Are you currently being treated for any medical conditions?(eg:No/if Yes,please specify)
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11.Please list any significant illness you have had.(eg:No/if Yes,please specify)
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12.Please list any hospitalization or operations you have had. (Please do NOT include the birth of your children)
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13.How close are you to the nearest hospital? What is the name / city it is located in?
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14.Have you ever been diagnosed with depression, anxiety, bipolar disorder, postpartum depression, or any other psychiatric condition?
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14.1Have you ever taken medications for depression or anxiety?(eg:No/if Yes,please specify)
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15.Have you or any of your partners ever been hospitalized for psychiatric illness?(eg:No/if Yes,please specify)
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16.Have you been immunized for Hepatitis B in the past? (This vaccine was not a standard childhood vaccination until 1992)
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Yes
No
Unsure
17.Have you ever been diagnosed with the following diseases? Herpes;Gonorrhea; Chlamydia; Syphilis; HPV; Genital warts;Heptatitis B;Hepatitis C (eg:No/if Yes,please specify)
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18.Has your partner/spouse ever been diagnosed with the following diseases? Herpes;Gonorrhea; Chlamydia; Syphilis; HPV; Genital warts;Heptatitis B;Hepatitis C (eg:No/if Yes,please specify)
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Characteristics
1.Why do you want to be a surrogate?What message would you like to give to your Intended Parents?
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2.Please describe your personality and character.
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3.What are your hobbies, interests and talents?
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4.What does your daily diet consist of?
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Decisions:
1.Are you willing to work with intended parents (IPs):
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hetero-sexual couples (male/female)
hetero-sexual individuals
same-sex couples (male/male or female/female)
same-sex individuals
2.Are you willing to work with International Intended Parents?(Please note we only work with US and Canada clinics)
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Yes
No
2.1.Are you willing to travel to Canada for physical screening as well as the embryo transfer?(Hybrid Program Only)
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Yes
No
3.Are you willing to carry for an intended parent/s who carries Hep B Virus?
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Yes
No
3.1.Are you willing to carry for an intended parent/s who does not carry Hep B virus,but recovered from an old infection (Not infected)?
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Yes
No
4.Are you willing to carry for an intended parent/s who have HIV?
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Yes
No
5.Are you willing to carry a child whereby the recipients used donor eggs or donor sperm?
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Yes
No
6.Are you willing to carry a child for a recipient who will raise this child in a religion different from your own?
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Yes
No
7.What kind of relationship do you want with the intended parents during conceptions and pregnancy?
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8.What is the maximum number of embryos are you willing to transfer per cycle
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8.1.Are you willing to carry twins if an embryo spilt?
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Yes
No
9.Are you willing to terminate for an abnormality/deformity?(Ex:Down Syndrome,Fragile x Syndrome,cleft palate,clibfoot,heart defect)
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Yes
No
10.Are you willing to terminate if your life or the baby life is in danger?
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Yes
No
11.Are you Okay with the reduction of multiples if medically necessary?
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Yes
No
12.Are you willing to terminate for gender?
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Yes
No
13.Are you willing to do somewhat invasive procedures during your surrogacy if medically necessary? For example, D&C, Amniocentesis and /or Chronic Villus Sampling.
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Yes
No
14.Are you willing to pump breast milk after birth?
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Yes
No
15.Would you be comfortable if the Intended Parents attended the OB appointments with you?
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Yes
No
16.Who are you willing to have in the delivery room?
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17.You will be required to take IVF medications. Some meds might require using injectable needles. Do you agree to take ALL medications required?
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18.Do you and your partner understand that you MUST agree to abstain from sexual activity while undergoing medical treatment and participating in this program?Any period(s) of abstinence will be directed by the physician
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