First Coast Surrogates: Minimum Qualifications

  • Pre-Screening Questionnaire

    These questions help to prepare for full screening.

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  • Format: (000) 000-0000.
  • Have you had a successful pregnancy resulting in a live birth?*

  • Authorization & Signature

  • By signing this form, I hereby authorize First Coast Surrogates to use my protected health information as a pre-screening qualification to become a surrogate. I understand the following to be true:

    • The authorization and information given is voluntary.
    • The information provided in this questionnaire is true.
    • To revoke First Coast Surrogate's right to use my information, I must submit a request in writing.
  • Date*
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  • Should be Empty: