Surrogate Mother Application

1
What is your full legal name* This field is required.Please list in first, middle, last format
First Name
Middle Name
Last Name
2
What is your date of birth* This field is required.
Date
Month
Day
Year
3
How did you hear about us?* This field is required.please be specific such as google, facbeook, a specific friend, etc.
4
Have you been a surrogate before?* This field is required.
YESNO
5
How many times have you been a surrogate before?* This field is required.
6
What is your blood type?* This field is required.
7
What is your height?* This field is required.If you are unsure please use best guess
8
What is your weight* This field is required.if unsure please use best guess
9
Have you gained/lost a significant amount of weight in the last year?* This field is required.
YESNO
10
What is your race/ethnic background?* This field is required.
11
What is your religious background?* This field is required.
12
Are you currently practicing in your religion?* This field is required.
13
Are you a US Citizen？* This field is required.
YESNO
14
If you are not a Us Citizen,please specify your citizenship and current legal status in United States* This field is required.
15
Are you single?* This field is required.If you put yes this means you are not in any type of sexual relationship currently. If you are sexually active we require that partners information.
YESNO
16
Are you married?* This field is required.
YESNO
17
What was the date of your marriage?* This field is required.lease use month/date/year format
18
What is your spouse's name ?* This field is required.
19
What is your spouses date of birth?* This field is required.
20
Are you widowed? If so, when was your partner deceased?* This field is required.
21
Have you ever experienced marital problems? If yes, please explain.* This field is required.
22
Have you ever been divorced?* This field is required.
YESNO
23
When did your divorce occur?* This field is required.
24
What was the cause of your break up?* This field is required.
25
Have you re-married? If yes, how long ago? * This field is required.
26
Are you legally separated?* This field is required.
YESNO
27
If you are separated, how long have you been married and how long have you been separated?* This field is required.
28
Do you have a Life Partner? If so, how long have you been together?* This field is required.If you are sexually active and your partner fits in no other category, their info goes here.
YESNO
29
What is your partner's full name and date of birth?* This field is required.
30
Are you engaged? If so, when was your engagement and when are you scheduled to be married?* This field is required.
31
Would you like to have any more children of your own in the future?* This field is required.
YESNO
32
Please list any problems you or your spouse/partner have experienced with the law including, but not limited to any arrests, convictions, and/or sentences.* This field is required.If yes please be specific
33
Have you or your spouse/partner ever served time in jail? If yes, how much time did you serve and for what?* This field is required.please be specific eith each instance, date of occurance, and what for.
34
What is the name of the nearest airport to your home and how many miles is it away from your home?* This field is required.please only include the name of commercial airports not private.
35
Do you have any pets? If yes, please list.* This field is required.if you have cats will someone be available to change the litter box?
36
Current Living Situation* This field is required.Please select your current housing status:
I own the place I live in
I rent the place I live in
I live with family members
37
Do you own or lease a car?* This field is required.
YESNO
38
Do you have a driver's license?* This field is required.
YESNO
39
Is your car insured?* This field is required.
YESNO
40
If you do not have a license how will you get to all necessary appointments?** This field is required.
41
How many siblings do you have?* This field is required.
42
How many siblings does your mother have?* This field is required.
43
Pregnancy History (Do NOT count as deliveries)* This field is required.Please indicate the number of each:
Miscarriages(before 20 weeks):
Elective abortions:
Ectopic pregnancies
44
Total Delivery Times(Count ONLY births at 20+ weeks)* This field is required.You will not be eligible to be surrogate for over 5 times delivery
Type how many times of delviery
45
Delivery #1 Year：* This field is required.
46
How Did You Conceive?* This field is required.Ex. naturally or with IVF
47
Date Of Delivery:* This field is required.
Date
Month
Day
Year
48
Birth Weight:* This field is required.
49
Gender* This field is required.
boygirl
50
Weeks Of Gestation To Delivery:* This field is required.ex.40 weeks
51
No Of Fetuses:* This field is required.
52
Pregnancy Resulted In:* This field is required.Ex. live birth, misscarriage
53
Delivery Method:* This field is required.
vaginallyc-section
54
Complications:* This field is required.such as high blood pressure, anemia (low iron), gestational diabetes, preeclapsia, post partum depression, etc
55
Delivery #2 Year：* This field is required.
56
How Did You Conceive?* This field is required.Ex. naturally or with IVF
57
Date Of Delivery:* This field is required.
Date
Month
Day
Year
58
Birth Weight:* This field is required.
59
Gender* This field is required.
boygirl
60
Weeks Of Gestation To Delivery:* This field is required.ex.40 weeks
61
No Of Fetuses:* This field is required.
62
Pregnancy Resulted In:* This field is required.Ex. live birth, misscarriage
63
Delivery Method:* This field is required.
vaginallyc-section
64
Complications:* This field is required.such as high blood pressure, anemia (low iron), gestational diabetes, preeclapsia, post partum depression, etc
65
Delivery #3 Year：* This field is required.
66
How Did You Conceive?* This field is required.Ex. naturally or with IVF
67
Date Of Delivery:* This field is required.
Date
Month
Day
Year
68
Birth Weight:* This field is required.
69
Gender* This field is required.
boygirl
70
Weeks Of Gestation To Delivery:* This field is required.ex.40 weeks
71
No Of Fetuses:* This field is required.
72
Gender* This field is required.
boygirl
73
Pregnancy Resulted In:* This field is required.Ex. live birth, misscarriage
74
Delivery Method:* This field is required.
vaginallyc-section
75
Complications:* This field is required.such as high blood pressure, anemia (low iron), gestational diabetes, preeclapsia, post partum depression, etc
76
Delivery #4 Year：* This field is required.
77
How Did You Conceive?* This field is required.Ex. naturally or with IVF
78
Date Of Delivery:* This field is required.
Date
Month
Day
Year
79
Birth Weight:* This field is required.
80
Gender* This field is required.
boygirl
81
Weeks Of Gestation To Delivery:* This field is required.ex.40 weeks
82
No Of Fetuses:* This field is required.
83
Pregnancy Resulted In:* This field is required.Ex. live birth, misscarriage
84
Delivery Method:* This field is required.
vaginallyc-section
85
Complications:* This field is required.such as high blood pressure, anemia (low iron), gestational diabetes, preeclapsia, post partum depression, etc
86
Delivery #5 Year：* This field is required.
87
How Did You Conceive?* This field is required.Ex. naturally or with IVF
88
Date Of Delivery:* This field is required.
Date
Month
Day
Year
89
Birth Weight:* This field is required.
90
Gender* This field is required.
boygirl
91
Weeks Of Gestation To Delivery:* This field is required.ex.40 weeks
92
No Of Fetuses:* This field is required.
93
Pregnancy Resulted In:* This field is required.Ex. live birth, misscarriage
94
Delivery Method:* This field is required.
vaginallyc-section
95
Complications:* This field is required.such as high blood pressure, anemia (low iron), gestational diabetes, preeclapsia, post partum depression, etc
96
Do you have health insurance?* This field is required.
YESNO
97
Does it have maternity coverage?* This field is required.
YESNot Sure
98
If you have health insurance please provide the following: * This field is required.(1) Name of the insurance company, (2)types of health insurance plans,etc PPO,HMO...
99
Is your health insurance provided through a state agency or program? If yes, what state agency or program?* This field is required.such as Medi-Cal
100
Do you pay for your health insurance privately or is it provided by an employer?* This field is required.
PrivatelyEmployer
101
What hospital do you intend to deliver your surrogate pregnancy? * This field is required.Please provide the name of the hospital
102
Have you delivered at the previously listed hospital before?* This field is required.
YESNO
103
Have you ever had an abnormal pap smear?* This field is required.
YESNO
104
Do your menstrual cycles occur monthly?* This field is required.
YESNO
105
How many days from the beginning of your period to the next month's first day of cycle?* This field is required.Menstrual cycle length,A normal cycle lasts between 21-35 days
106
How many days does your period last?* This field is required.
107
Date of Last Menstrual Period :* This field is required.
108
Have you ever been seen by a doctor for infertility?* This field is required.
YESNO
109
if yes please explain* This field is required.
110
Do you currently or have you ever smoked cigarettes or ANY form of nicotine ? * This field is required.This will show up on medical records as well
YESNO
111
If yes, did you ever smoke during pregnancy?* This field is required.
YESNO
112
Do any members of your household smoke cigarettes or ANY form of nicotine?* This field is required.
YESNO
113
If yes, where and how often?* This field is required.
114
Do you or any members of your household smoke or injest marijuana?* This field is required.
YESNO
115
Do you drink alcohol? * This field is required.
YESNO
116
If yes, how much and how often?* This field is required.
117
Have you ever used illegal drugs or unprescribed drugs?* This field is required.
YESNO
118
Has your partner/husband used illegal drugs or unprescribed drugs?* This field is required.
YESNO
119
Please list the Name(s), Age(s), and Gender(s) of your children.* This field is required.
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120
Did you suffer any emotional or physical problems during and/or after each of your pregnancies?* This field is required.
YESNO
121
If yes please explain.* This field is required.
122
Do any of your children have serious health problems? * This field is required.
YESNO
123
If yes, please explain* This field is required.
124
Are you currently breastfeeding?* This field is required.
YESNO
125
If so, when do you plan to stop?* This field is required.
126
Have you ever had any surgery? * This field is required.
YESNO
127
If yes, reason and results?* This field is required.
128
List any serious illnesses you have.* This field is required.
129
List all hospitalizations (except for childbirth)* This field is required.
130
List all medications that you are presently taking and for what reason* This field is required.
131
Have you had a tattoo or body piercing in the last year and a half? * This field is required.please note if you would like to move forward with surrogacy you cannot get any new tattoos past this point. Clinics require 6 months to one year with no new tattoos.
YESNO
132
If yes, when?* This field is required.
133
Have you ever been seen by a professional for mental health issues?* This field is required.
YESNO
134
If yes, please explain and list time periods* This field is required.
135
Have you ever experienced any postpartum depression? * This field is required.
YESNO
136
If yes, please give the details and time periods* This field is required.
137
Have you ever been prescribed any medication for depression or mental health? * This field is required.
YESNO
138
If yes, please list medication name, reason for use and dates of use* This field is required.
139
Have you ever had any problems with drug or alcohol abuse? * This field is required.
YESNO
140
Are you exposed to excess heat in the way of saunas, hot tubs and/or steam rooms?* This field is required.
YESNO
141
Do you have any allergies? * This field is required.
YESNO
142
If yes, please explain in detail* This field is required.
143
Have you been vaccinated for Hepatitis B?* This field is required.
YESNO
144
Have you ever been advised to limit your use of alcohol or any other drug?* This field is required.
YESNO
145
List any contraceptives you have used in the past and any reaction you have had to the use of the contraceptive including Tubal Ligation.* This field is required.
146
Are you currently using birth control?* This field is required.ex. Tubal Ligation, Vasectomy, B.C. pills, condoms
YESNO
147
If you are currently using birth control, which method do you use and how long have you been using this method?* This field is required.
148
Are you with a sexual partner now?* This field is required.
YESNO
149
Do you currently have more than one sexual partner?* This field is required.
YESNO
150
How many sexual partners have you had in the last three years?* This field is required.
151
In the past 10 years have you had sexual contact with anyone in a high-risk group for HIV or AIDS? These include sexually active partners with multiple partners and partners who have used illegal drugs* This field is required.
YESNO
152
Are you at risk for HIV or AIDS?* This field is required.
YESNO
153
Have you ever received a blood transfusion?* This field is required.
YESNO
154
Have you ever had or have a sexually transmitted infection or disease? If yes, please explain. * This field is required.please note HPV is an STI and needs to be listed here
YESNO
155
If yes, please explain. * This field is required.please note HPV is an STI and needs to be listed here
156
Please list your current place of employment. Include (1) position held, (2) date of employment and (3) location of employer. If not applicable please state "N/A".* This field is required.If you are self employed please list what you do specifically
157
What is your current monthly income?* This field is required.
158
Please list your husband/partner's current place of employment. Include (1) position held, (2) date of employment and (3) location of employer. If not applicable please state "N/A".* This field is required.
159
What is your Spouse's/Partner's current monthly income?* This field is required.
160
How many persons do you support including yourself?* This field is required.
161
Are you receiving food stamps or any other public assistance?* This field is required.
YESNO
162
How many people are currently living in your home? If other than your children, husband/spouse who are they?* This field is required.
163
What was your highest level of education obtained?* This field is required.
High SchoolCollege
164
If you completed your education through a trade school, please specify.
165
Briefly explain your understanding of what being a gestational carrier will entail?and your motivation for becoming a surrogate mother.* This field is required.
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166
Generally please introduce yourself: personality, hobbies, interests,family support.......?* This field is required.This helps intended parents get an idea of who you are
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167
What are your main concerns about the surrogacy process?* This field is required.(Select all that apply)
Medical procedures
Pregnancy risks
Time commitment
Impact on my family
Emotional challenges
Legal issues
Compensation and payments got paid on time
Communication with intended parents
agency can provide timely support when needed
168
What qualities if any would you consider most important that the parents you choose will have?* This field is required.
169
Do you have any preferences for the religious background of the parents? * This field is required.
YESNO
170
Would you be willing to work with an unmarried couple or person?* This field is required.
YESNO
171
Would you be willing to work with a heterosexual couple?* This field is required.Male/Female
YESNO
172
Would you be willing to work with a same sex couple?* This field is required.
YESNO
173
Would you be willing to work with a single male?* This field is required.
YESNO
174
Would you be willing to work with a single female?* This field is required.
YESNO
175
Would you be willing to work with a couple using an egg donor?* This field is required.
YESNO
176
Would you be willing to work with a couple using a sperm donor?* This field is required.
YESNO
177
Would you be willing to work with an older couple?* This field is required.
YESNO
178
Would you be willing to work with a couple with children?* This field is required.
YESNO
179
Would you be willing to work with an international couple?(a couple living outside of the United States)* This field is required.please keep in mind most intended parents will not be located in the U.S.
YESNO
180
Would you be willing to work with a non-English speaking couple using a translator?* This field is required.
YESNO
181
Are you willing to carry twins?* This field is required.
YESNO
182
In the case of a multiples pregnancy, are you willing to reduce the pregnancy from 3 to 2 or 1?* This field is required.
YESNO
183
Would you be willing to undergo amniocentesis or other diagnostic testing to determine the presence of birth defects?* This field is required.
YESNO
184
If there were a serious problem with the fetus and the parents wanted to abort would you be willing to abort in the presence of birth defects?* This field is required.
YESNO
185
How much contact would you like to have with the parents throughout the process?* This field is required.
186
How much contact would you like to have with the parents after the birth?* This field is required.
187
Do you have any concerns about placing the baby with the parents after you give birth?* This field is required.
YESNO
188
Will you permit the parents in the delivery room?* This field is required.
YESNO
189
Will you permit the parents to attend doctor appointments if they want to attend?* This field is required.
YESNO
190
Will you permit the parents to notify the hospital that you are not the biological parent of the child?* This field is required.
YESNO
191
Will you allow the parents' names to be placed on the birth certificate?* This field is required.
YESNO
192
Are you currently applying to be a gestational carrier at any other medical facility, agency, and facilitator, or independently?* This field is required.
YESNO
193
Have you ever applied to be a gestational carrier at any other medical facility and been told that you do not meet the criteria to be a gestational carrier? * This field is required.
YESNO
194
Are you able to attend all prenatal check‑ups on time?* This field is required.
YESNO
195
Are you willing to receive injections, medications, and ultrasounds as required?* This field is required.
YESNO
196
Are you willing to undergo all medical examinations designated by the doctor ?* This field is required.
YESNO
197
Are you able to follow pregnancy‑related lifestyle guidelines?* This field is required. (diet, rest schedule, etc.)
YESNO
198
Are you willing to avoid long‑distance travel during pregnancy?* This field is required.
YESNO
199
Are you willing to refrain from high‑risk work during pregnancy?* This field is required.
YESNO
200
Have you ever placed a child up for adoption?* This field is required.
YESNO
201
What kind of support do you expect to have while being a gestational carrier from intended parents, and our agency? Please be specific.* This field is required.
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202
Is there anyone important in your life that is not supportive of you considering becoming a gestational surrogate?* This field is required.
YESNO
203
How does your husband/partner feel about your participating in the surrogacy process? * This field is required.please note your partner wil be required to complete bloodwork and sign your contract.
204
Do you feel like you will have the neccessary support to be able to find adequate child care for all appointments you will be required to attend?* This field is required.children are not allowed at Ivf clinics for any reason, childcare is required for all appointments.
YESNO
205
Please upload your 6 pictures* This field is required.You are beautiful just the way you are so please do not use filtered photos. Please also include at least one full body photo,one group photo with your kids
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
206
I hereby authorize Babytree Surrogacy to disclose the information contained in this Surrogate Application to anyone interested in reviewing my application to assist them in selecting a Surrogate, and for review by appropriate medical and psychological professionals and their staffs. I understand, and expressly condition this authorization upon such understanding.
207
Applicant Name* This field is required.
First Name
Last Name
208
Application Date* This field is required.
Date
Month
Day
Year
209
Applicant signature：* This field is required.
Powered by Jotform SignClear
210
Applicant Email* This field is required.
example@example.com
211
Applicant Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
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Aruba
Australia
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The Bahamas
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Benin
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Brazil
Brunei
Bulgaria
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Christmas Island
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Democratic Republic of the Congo
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Mali
Malta
Marshall Islands
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Mauritania
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Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
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Nigeria
Niue
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Norway
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Peru
Philippines
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Poland
Portugal
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Qatar
Republic of the Congo
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Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
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Saint Vincent and the Grenadines
Samoa
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Saudi Arabia
Senegal
Serbia
Seychelles
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South Africa
South Ossetia
South Sudan
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Suriname
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eSwatini
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Tanzania
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Timor-Leste
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Tonga
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Trinidad and Tobago
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
212
Applicant Phone Number* This field is required.
Please enter a valid phone number.
213
Emergency Contact person's name ,relationship and Phone Number* This field is required.must be different as your own number
Should be Empty: