New Grace - Surrogate Application

New Grace - Surrogate Application
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Ethnicity*
Instagram
Feel free to share your Instagram if you're comfortable. We will only use this for application review and communication purposes.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Current Age*
Height: Feet*
Inches*
What is your current weight? (LBS)*
BMI
Occupation*
Marital Status*
Highest Level of Education*
Religion*
Are you a U.S. Citizen or Permanent Resident? *
Do you have any criminal record?*
How many pregnancies have you had?*
Number of children (non surrogate) *
Tell us a little bit more about your children. (DOB/Gender/Birth weight/Delivery Method/What week was he/she born)*
● First Child
DOB: 
Gender: 
Birth weight (lbs): 
Delivery method: 
What week of pregnancy was the baby born? 

● Second Child
DOB: 
Gender: 
Birth weight (lbs): 
Delivery method: 
What week of pregnancy was the baby born? 

● Third Child
DOB: 
Gender: 
Birth weight (lbs): 
Delivery method: 
What week of pregnancy was the baby born? If you have more than 3 kids, please indicate their info as well. Thanks!
Do you have surrogate experience, if yes, how many times?*
Number of surrogate children*
Tell us a little bit more about your surrogate history. (DOB/Gender/Birth weight/Delivery Method/What week was he/she born)*
● First Surrogate Child
DOB: 
Gender: 
Birth weight (lbs): 
Delivery method: 
What week of pregnancy was the baby born? 

● Second Surrogate Child
DOB: 
Gender: 
Birth weight (lbs): 
Delivery method: 
What week of pregnancy was the baby born? 

● Third Surrogate Child
DOB: 
Gender: 
Birth weight (lbs): 
Delivery method: 
What week of pregnancy was the baby born? If you have more than 3 surrogate children, please indicate their info as well. Thanks!
How many embryos are you willing to transfer?*
Single、Double or Multiple Embryo Transfer
How many times of embryo transfers are you willing to do?*
Are you willing to carry twins? Do you understand and accept the risks and confirm that you are still willing to proceed with carrying a twin pregnancy?*
Please select one below:
1. Yes, I am willing to carry twins & I understand the risks.
2. No, I am not willing to carry twins.If you are willing to carry a twin pregnancy, please be advised that twin gestation is considered a high-risk pregnancy compared to a singleton pregnancy. You may have a significantly higher likelihood of being required to follow medical instructions such as bed rest and may face an increased risk of preterm labor.By ansewering "Yes, I understand", you acknowledge that you understand and accept these risks and confirm that you are still willing to proceed with carrying a twin pregnancy.
Are you willing to have an abortion if necessary? (for the health of surrogate baby)*
If the fetus were diagnosed with down syndrome (trisomy 21), would you be willing to terminate the pregnancy?*

YesNo
What is your expected base compensation? (currency is in USD)*
When was your last pap smear?*
Do you have a regular menstrual cycle?*

YesNo
Have you experience any complications during any of your pregnancy or delivery? *
If yes, when was it?
Have you had any miscarriage(s)? *
If yes, when was it?
How many C-sections have you had?*
Any tattoos or piercings in six months?*
Do you chew tobacco, vape, or smoke cigarettes?*

YesNo
Do you engage in other forms of recreational drug use or consume excessive amounts of alcohol?*

YesNo
Have you been diagnosed with a mental health disorder?*

YesNo
Are you willing to match with intended parents who have Hepatitis B?*
Have you been vaccinated for Hepatitis B? If not, are you willing to get a Hepatitis B vaccine?*
Are you willing to take the vaccination recommended by the doctor?*

YesNo
Are you willing to take hormone medication that is required to prepare your body for embryo transfer & the pregnancy?*

YesNo
What kind of birth control are you currently using?*
Are you receiving any government assistance?*
Do you have insurance? What kind is it?*
What are your hobbies?*
How would your friends describe you? What’s your personality?*
About you: (briefly introduce yourself)*
Do you have anyone who will support you during your surrogacy journey? Please list those who will support you during your surrogacy journey*
What type of relationship would you like to have with the intended parent(s) after the baby is born?*
A message to intended parents:*
Share photos of you with us! (About two or three photos of you,and two photos with family and children if possible, thank you!) *

Cancelof
How did you hear about us? Who referred you? (Please list the name of the person who referred you (if any)*
In the end, tell us why you want to be a surrogate. :)*
Partner's Details
Partner's Name*
Partner's DOB*

MonthDayYear
Date
Partner's Ethnicity*
Partner's Occupation*
Describe your partner's health :)*
How long have you been in a relationship with your partner?
As part of process, your partner would need to take a required blood test (for infectious diseases and drug screening). Are they comfortable with that?*
Should be Empty:

New Grace - Surrogate Application

Partner's Details