Accel Conceptions Surrogate Profile
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
*
Please Select
Facebook
Friend
Google
Instagram
TikTok
Kimmi Sanchez Social Media
Lennon (The Sinclair Pair) Social Media
Other
Who is your friend that referred you? We would love to thank them!
*
Please describe:
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Weight
*
Height
*
———
*
Total Height (inches)
BMI (Result)
Do You Speak Another Language?
*
Yes
No
What Language?
*
Do you have health insurance?
*
Yes
No
Who is your health insurance obtained through?
*
My Employer
My Spouse/Partner’s Employer
Medi-cal/Medicaid
Do you have a valid Driver’s license?
*
Yes
No
Tell your future Intended Parent(s) about yourself, your family, a why you wanted to be a surrogate
*
What is your Ethnic Background?
*
Are you a U.S. citizen?
*
Yes
No
Are you a Legal Resident?
*
Yes
No
Are you an active member of the Native American Tribe?
*
Yes
No
What tribe?
*
Family & Living Status
What is your marital status?
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Married
Engaged
In Relationship (living together)
In Relationship (living separately)
Single
Divorced
Legally Separated
Separated (non-legal)
Other
Have you ever been legally married?
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Yes
No
Is your partner a U.S. citizen?
*
Yes
No
Please explain your marital status:
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How long have you been together?
*
Describe your relationship:
*
Is your partner employed?
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Yes
No
Describe your partner’s job and work schedule:
*
Describe your relationship and custody arrangement with your child(ren)'s biological father:
*
Are you actively looking to date?
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Yes
No
Is your partner supportive of surrogacy?
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Yes
No
Who will be your main support during pregnancy?
*
Are you employed?
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Yes
No
Describe your occupation and schedule:
*
Does anyone smoke/vape in the house?
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Yes
No
Are they willing to only smoke/vape outside or away from you?
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Yes
No
Do you have any pets in the home?
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Yes
No
Do you have a cat in your home?
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Yes
No
Who will change the litter box?
*
Do you have reliable transportation?
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Yes
No
How will you attend appointments?
*
Are you willing to travel outside of your hometown to attend IVF appointments? (2-10 times, all travel expenses are a covered benefit)
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Yes
No
Explain why not:
*
List everyone living in your home:
*
Medical History
Blood Type
*
Please Select
A+
A-
B+
B-
AB+
AB-
O+
O-
Not Sure
Do you take any medications besides vitamins including anti-depressant or anxiety medications?
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Yes
No
List medication and dosage:
*
Have you ever been diagnosed with a mental health disorder (such as anxiety, depression, bi-polar disorder etc.) and required medical treatment, medication, or prescription?
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Yes
No
Explain the diagnosis and treatments:
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Have you (or a partner if applicable) ever been under the care of a psychologist?
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Yes
No
Please explain:
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Have you (or a partner if applicable) ever been admitted to a substance abuse program?
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Yes
No
Please explain:
*
Have you (or your partner, if applicable) had a history of, or been treated for, anger management?
*
Yes
No
Please explain:
*
Please explain the condition, year of diagnosis, and if there is medication required:
*
Have you (or your partner if applicable) ever been arrested?
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Yes
No
Please explain:
*
Have you ever placed a child up for adoption?
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Yes
No
Please explain:
*
Select any of the following medical conditions you have been diagnosed with:
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Auto Immune Disease
Blood Disorder
Cardiovascular Conditions
Chronic Mental Health Conditions
Gastrointestinal (GI) Tract Issues
Genetic Disorders
Gynecological Issues
Neurological Conditions
PCOS/Endometriosis
Pulmonary Conditions
Thyroid Disorders
Other
None
Explain the condition and any treatment if applicable:
Do you agree to take all prescribed IVF injectables, oral, vaginal medications, and/or adhesive patches, which can last up to 16 weeks?
*
Yes
No
Select your method of birth control:
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IUD
Birth Control Pill
Condom
Implanon/Nexplanon
Nuva Ring
Vasectomy
Tubal Ligation
Depo-Provera Shot
Birth Control Patches
Same Sex Partner
Abstinence
None
Are you currently breastfeeding?
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Yes
No
Have you had any of the following complications during pregnancy?
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Bedrest
Blood Transfusion
Cervical Cerclage
Gestational Diabetes diet controlled
Gestational Diabetes requiring medication
High Blood Pressure/ Pre-Eclampsia
Hospitalization (Other than birth)
Hospitalization (for something other than birth)
Placenta Abruption
Placenta Previa
Postpartum Depression
Postpartum Hemorrhage
Preterm Labor (Early birth before 37 weeks)
Shortening of Cervix
None
If you marked any of the above, please provide details:
*
Do you have a history of a diagnosed sexually transmitted disease?
*
Yes
No
Please explain:
*
When was your last annual exam (PAP smear)?
*
Do you have a history of an abnormal PAP smear?
*
Yes
No
Please explain the year of abnormal result, and the treatment:
*
In past pregnancies have you missed any appointments?
*
Yes
No
Why?
*
Are you vaccinated for Varicella (chicken pox)?
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Yes
No
Unsure
Are you willing to receive a Varicella (chicken pox) vaccine/ booster?
Yes
No
Are you vaccinated for Hepatitis B?
*
Yes
No
Unsure
Are you willing to receive a Hepatitis B vaccine/ booster if needed?
Yes
No
Are you vaccinated for Covid?
*
Yes
No
Unsure
Are you willing to receive a Covid vaccine/ booster if needed?
Yes
No
Are you immunized for MMR (Measles, Mumps, and Rubella)?
*
Yes
No
Are you willing to receive a MMR booster if needed?
Yes
No
Are you willing to receive the MMR vaccine?
Yes
No
Have you had any surgeries?
*
Yes
No
What was the operation and year completed?
*
Do you have any known food allergies?
*
Yes
No
What are you allergic to?
*
Describe your typical breakfast, lunch, dinner and snack:
*
Have you used any medical/recreational marijuana in the last 3 months?
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Yes
No
Did you ever use tobacco products (including a vape which could contain nicotine) during your own pregnancy?
*
Yes
No
Did you use drugs (including marijuana) during your pregnancy?
*
Yes
No
Did you ever consume alcohol during your own pregnancy?
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Yes
No
Do you agree to undergo Drug Screening by urine &/or blood at any time during the surrogacy, including pre-screening?
*
Yes
No
Do you understand that if accepted into the program, the use of products containing nicotine, tobacco, THC, illicit drugs, or the consumption of alcohol is prohibited? (This includes pre-screening, medical screening, pregnancy and postpartum, not putting yourself, the surrogacy, or pregnancy at risk.)
*
Yes
No
List your pregnancy history:
*
Do you have a history of miscarriages?
*
Yes
No
Please explain the year and week of gestation:
*
Do you have a history of elective terminations?
*
Yes
No
Please explain year and week of gestation:
*
Surrogate Preferences
Check all IP’s (intended parents) you are willing to be matched with:
*
IPs who already have children
Same-sex IPs
Single male
Single female
International IPs (You will not need to travel outside the U.S.)
IPs who are HIV+ (advanced sperm washing removes the virus before the embryo is created)
IPs who are Hepatitis B carriers or have positive exposure (your vaccines must be current to prevent exposure)
Unsure, I would like to chat more about it.
Are you willing to carry twins?
Yes
No
Are you willing to reduce from twins to a singleton? (terminate one fetus to remain pregnant with a singleton)
Yes
No
Do you understand that a single embryo can split into identical twins?
Yes
No
In that case are you willing to carry twins?
Yes
No
Are you willing to terminate at the Intended Parent(s) request due to chromosomal, or developmental abnormalities that would affect the baby's viability or quality of life?
Yes
No
Do you understand that if medically recommended, amniocentesis may be performed? (The sampling of amniotic fluid using a hollow needle inserted into the abdomen, to screen for developmental abnormalities in a fetus.)
Yes
No
Tell your future Intended Parent(s) about how you spend your free time (hobbies, weekend activities, your interests etc.) :
*
Upload a photo of yourself for your application:
*
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