Surrogacy Application

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

Date

Place of Birth: City/Country

Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about Eggvise?

Ethnicity

Maternal Heritage (Where is your mother from?)

Paternal Heritage (Where is your father from?)

Are you adopted?

Please indicate your religion

Height

Weight

Eye Color

Natural Hair Color

Hair Texture

Complexion

Do you have Freckles?

Corrective Dental?

Do you currently wear glasses?

Marital Status

Are you a US Citizen or have permeant residency?

Are you legal in United States? Please explain

Where were you born?

What amount are you seeking as compensation?

We would love to get to know you a bit more. How would you describe your personality? Tell us how you see yourself and what makes you unique. This will help future parents get to know you better and understand a little more about who you are.

Have you been a surrogate in the past?

How many times?

Tell us, what motivates you to become a surrogate? We would love to know more about what inspires you to make this decision

What is your favorite type of food?*

If you could say something to Intended Parents, what message would you like them to know?

Current Level of Education

Name of the College currently attending or attended

Major

If in US, College Grade Point Average (GPA)

Current Occupation

Do you have a learning disability?

Do you have any musical talents? If any, please list.

Do you play sports or exercise? please explain.

How often do you exercise?

Do you have both of your ovaries?

At what age did you first experience your menstrual cycle?

Do you have a regular menstrual cycle? If not, please describe any irregularities

Current method of birth control.

Are you currently sexually active?

Have you ever been pregnant?

Did you experience any medical issues during your pregnancy? If so, please provide details.

How Many Children do you have?

Are you currently breastfeeding? If yes, please provide details.

Do you currently have or have you ever had any sexually transmitted infections (STIs)? If so, please specify if they were treated by a doctor.

Have you ever had an abortion? If so, please provide details.

Have you ever had a stillborn baby?

Have you experienced a miscarriage before?

Do you get a regular period?

Have you ever found a lump on your breast before?

Date of your last pap smear. (If none put N/A)

What were the results of your last pap smear?

Have you received a COVID-19 vaccine? If yes, please specify the type of vaccine (e.g., Pfizer, Moderna, Johnson & Johnson) and the dates of vaccination, if known.

Are you currently treating any diseases? If so, please list.

Are you taking any prescription or over the counter medications? If yes, please explain

Have you been tested as a carrier of Thalassemia? If yes, please explain.

Have you been tested for being a Cystic Fibrosis carrier? If yes, please explain.

Have you been tested as a carrier for the Sickle Cell disease? If yes, please explain

Have you ever had any surgeries or significant medical treatments? Please provide details.

Have you had any complications during previous pregnancies or deliveries?

Are you willing to undergo regular drug and alcohol testing throughout the surrogacy process?

Have you gotten any tattoos in the past 12 months?

Have you had any piercings in the past 12 months?

Have you ever been diagnosed with cancer?

Do you have any birth defects?

Have you ever had any STI/STDs?

Have you ever had syphilis or gonorrhea?

Have you ever had hepatitis B or C?

Have you ever had a blood transfusion?

Have you ever been rejected for a blood transfusion?

Do you or any of your family members have a history of easily bruising or bleeding?

Have you ever had serious mental health issues?

Have you ever been clinically diagnosed with depression or bipolar disorder?

Have you ever taken antidepressants or anxiolytics? Explain why.

Do you have any allergies? If so, please specify.

Have you undergone any cosmetic surgeries in the past year? If so, please specify the type of surgery

Do you drink coffee? How often (daily or weekly)?

Do you drink alcohol? How often (daily or weekly)?

Do you smoke, vape, or use marijuana? How often (daily or weekly)?

Does your family have twins or triplets? Please specify

Do you or any of your family members have genetic disorders？

Do you have any direct family member with autism? please explain

Are you willing to undergo a psychological evaluation as part of the surrogacy process?

Do you have any concerns or preferences about working with the intended parents (e.g., communication, involvement)?

Are you comfortable with breastfeeding/pumping for the baby after delivery?

Are you comfortable with a C-section if necessary?

Are you open to maintaining contact with the intended parents after delivery?

Would you be willing to undergo counseling with the intended parents if necessary?

Do you have any preferences regarding the intended parents (e.g., single, heterosexual, LGBTQ+)?

How do you feel about having the intended parents present during delivery? please explain

How do you feel about sharing updates and ultrasound images during pregnancy? please explain

What level of communication do you prefer with the intended parents (frequent, occasional, minimal)? please explain

Do you have a stable living environment?

Do you follow any particular diet or lifestyle choices (e.g., vegan, gluten-free, etc.)?

Are you willing to abstain from smoking, drinking, and drug use during pregnancy?

Do you have a supportive partner, family, or friends who are willing to support you throughout the surrogacy process?

Will you have a support person (e.g., spouse, friend) attend appointments or be involved in the pregnancy process?

Are you willing to undergo regular medical screenings and appointments as required by the surrogacy program?

Do you work full-time or part-time? If so, what is your occupation? please explain

How would you describe your diet and exercise habits? please explain

Are you currently involved in any legal disputes or custody battles?

Do you have health insurance that will cover the pregnancy? If not, are you willing to obtain additional coverage?

Are you comfortable with the legal contracts required for surrogacy?

Are you currently receiving government assistance (e.g., Medicaid, food stamps, housing aid)?

Are you open to undergoing a criminal background check?

Do you have any history of legal issues (e.g., criminal charges, family law matters)?

Is there anything else you feel is important for us to know about you or your situation?

Mother - Current age

Age at death and cause of death (if applicable)

Health Conditions

Height

Eye Color

Natural Hair Color

Occupation

Father - Current age

Age at death and cause of death (if applicable)

Health Conditions

Height

Eye Color

Natural Hair Color

Occupation

Maternal Grandfather - Current age

Age at death and cause of death (if applicable)

Health Conditions

Height

Eye Color

Natural Hair Color

Occupation

Maternal Grandmother - Current age

Age at death and cause of death (if applicable)

Health Conditions

Height

Eye Color

Natural Hair Color

Occupation

Paternal Grandfather - Current age

Age at death and cause of death (if applicable)

Health Conditions

Height

Eye Color

Natural Hair Color

Occupation

Paternal Grandmother - Current age

Age at death and cause of death (if applicable)

Health Conditions

Height

Eye Color

Natural Hair Color

Occupation

Do you have siblings?

How many siblings do you have? Please specify.

Please provide 10-20 photos from different stages of your life, including a recent full-body photo. No group photos, as these will help intended parents in making their decision. A minimum of 10 photos is required

Surrogacy Questionnaire

Personal

Education

OB-GYN

Medical History

Surrogacy Preferences

Lifestyle and Support System

Legal and Financial

Family History

Photo Uploads