Surrogacy application
Name
*
First Name
Last Name
Other names used/Maiden name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Age
*
Weight in LBS
*
BMI (Body Mass Index)
*
Use a BMI calculator on google if unsure
Height (Feet)
*
Height (Inches)
*
Are you a US Citizen or Green Card holder?
*
Please Select
Yes, I am a US Citizen
Yes, I am a Green card holder
No
If you are a Green Card holder, when does your Green Card expire?
City and State of residence
*
Ex: Nashville, Tennessee
What languages are you fluent in?
*
Ex: English, Spanish
What is your primary spoken language?
*
Ex: English, Spanish
Marital Status
*
Ex: Married but separated, Married, Single, etc.
Name of partner/spouse (If applicable)
How many total childbirths have you had?
*
Please Select
O
1
2
3
4
5
6+
Have you ever had a premature birth?
*
Please Select
Yes
No
How many C-sections have you had?
*
Please Select
O
1
2
3
4+
Did you have any complications during any of your pregnancies?
*
Please Select
Yes
No
If yes to the previous question, please explain…
Did you have any complications during or after any of your deliveries?
*
Please Select
Yes
No
If yes to the previous question, please explain…
Are you currently on birth control?
*
Please Select
Yes
No
If yes to the previous question, What type of birth control are you using?
Pill, shots, patches, etc.
Do you have legal custody of ALL of your children?
*
Please Select
Yes
No
Do you have valid drivers license or state ID
*
Please Select
Yes- Drivers license
Yes- State ID
No
Do you have reliable transportation?
*
Please Select
Yes- I lease or own a vehicle
Yes- I use public transportation
Yes- Family/Friends transport me
No- I do NOT have reliable transportation
Please check all that apply:
I currently smoke cigarettes or use nicotine products or have used them in the past 6 months.
I currently smoke marijuana or consume marijuana products (Edibles, gummies, Delta 8/Delta 9 products included) Or have used them in the past 6 months.
I currently vape or use e-cigarettes or have used them in the past 6 months.
I currently use drugs OR I have used drugs in the past.
I have had an addiction to drugs or alcohol in the past.
How often do you drink alcohol?
*
Please Select
Never
Rarely: once every few months
Occasionally: 1-2 times per month
Weekly: 1-2 times per week
Regularly: 5+ days a week
Please check all that apply:
Someone that lives in my household currently smokes cigarettes or uses nicotine products.
Someone that lives in my household currently smokes marijuana or consumes marijuana products (Edibles, gummies, Delta 8/Delta 9 products included).
Someone that lives in my household currently vapes or uses e-cigarettes.
Someone that lives in my household currently uses drugs OR has used drugs in the past 6 months.
Someone that lives in my household has an addiction to drugs or alcohol OR has had an addiction to drugs or alcohol in the past.
Please check all that apply:
I have been convicted of a crime.
I have been convicted of a felony.
Someone in my household or my partner/spouse (over the age of 18) has been convicted of a crime.
Someone in my household or my partner/spouse (over the age of 18) has been convicted of a felony.
Please check all that apply:
I have had a miscarriage.
I have had an abortion.
I have had preeclampsia.
I have had HELLP Syndrome.
I have had Gestational diabetes that was diet controlled.
I have had Gestational diabetes that was controlled by medications or Insulin.
I have had placental abruption or previa.
I have had a postpartum hemorrhage that required a blood transfusion.
I have had a postpartum hemorrhage that did NOT require a blood transfusion.
Please select all that apply:
I have been diagnosed with Diabetes.
I have been diagnosed with Hypertension.
I have been diagnosed with Thyroid disorders.
I have been diagnosed with Autoimmune disorders, such as: Lupus, Rheumatoid Arthritis, Multiple Sclerosis, etc.
I have been diagnosed with Heart disease.
I have been diagnosed with Kidney or liver disease.
I have been diagnosed with a neurological disorder, such as: Epilepsy, seizures, stroke, etc.
Mental Health Questions: Please select all that apply.
I have been diagnosed with Depression/Postpartum Depression either currently or in the past.
I have been diagnosed with anxiety either currently or in the past.
I have been diagnosed with Bipolar Disorder.
I have been diagnosed with PTSD.
I have been diagnosed with Schizophrenia or a Psychotic disorder.
I have self harmed myself or attempted suicide.
I have been a victim of sexual or physical assault.
Do you currently take any medications to treat depression or anxiety or have you in the past 6 months?
*
Yes, I currently take medications to treat depression/anxiety.
Yes, I have taken medications to treat depression/anxiety in the past 6 months, but I am not currently taking any.
No, I have not taken medications to treat depression/anxiety in the past 6 months.
Have you ever had a bad result from an evaluation/pap? Example: Positive for an STD, HIV, Hep B or C, STI, Tuberculosis, etc? If yes, please explain below.
*
Was your most recent evaluation/pap normal?
*
Yes
No
When was your last evaluation/pap?
*
Do you have a regular menstrual cycle?
*
Yes
No
Have you ever had any kind of fertility treatment?
*
Yes
No
Do you have both ovaries?
*
Yes
No
Have you been a surrogate before?
*
Yes
No
Feel free to add anything below that you would like us to know regarding the questions above OR any info you would like to share with us.
How did you hear about Woven Branches Surrogacy?
*
Please Select
Facebook
Instagram
TikTok
Lemon 8
Google
Family/Friend
Other
Please explain the above if you selected “Other” OR share the name of the person who referred you to us. (So we know who to thank).
Save
Submit
Should be Empty: