Gestational Carrier Form
Please complete this secure intake form. Your information will be handled in accordance with HIPAA privacy requirements.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Gestational Carrier Questionnaire
What is your primary reason for pursuing gestational surrogacy?
Do you have any religious/culture requirements?
Have you been a gestational carrier before?
Yes
No
Are you currently working with an agency or clinic?
Yes
No
Marital/Relationship Status
Married
Single
Domestic Partnership
Do you have reliable transportation?
Yes
No
Do you smoke/vape/ or use nicotine products?
Yes
No
Any drug or alcohol use? Be honest as it is part of the medical clearance regardless.
Yes-currently.
Yes- previously.
No.
How many times have you been pregnant?
1
2
3
4
5
6
How many live births?
Please Select
1
2
3
4
5
6
How many vaginal births?
How many c-sections?
Any pregnancy complications? Births before 37 weeks, Gestational Diabetes, Preeclampsia, etc.
Most recent delivery date
-
Month
-
Day
Year
Date
Have you been advised not to get pregnant again?
Yes
No
Are you currently breastfeeding?
Yes
No
Have you received medical clearance for a surrogacy journey?
Yes
No
I need help with this.
What is your current BMI? (This is a requirement for some clinics.)
Any diagnosed medical conditions (if you’re not sure, list it anyways)
Any mental health history? (Diagnosed by a doctor/ and or received support for it? This does not necessarily disqualify individuals but will be asked in medical clearance.
Yes
No
Any previous surgeries? What and when?
Do you have health insurance? If so, with whom?
If applicable, is your health insurance surrogate friendly?
Yes
No
I am not sure.
N/A
Does your partner support a surrogacy journey?
Yes
No
N/A
Are you open to carrying for?
Single parent
Same-sex couple
International Parents
Heterosexual
What are your views on selective reduction and terminations?
Are you willing to do a DET?
Yes
No
Are you willing to carry multiples (sometimes SET can split)?
Yes
No
Are you willing to travel for the transfer?
Yes
No
When do you want to start?
As soon as possible
1-3 months
3-6 months
Not sure yet.
What is your hope for your base compensation?
Are you vaccinated? Open to vaccines? Explain your expectations for vaccines.
Are you taking any medications? If so, please list them.
Are you employed?
Yes
No
Self Employed
Will you need childcare support for appointments, delivery, travel, and post birth care?
What are your preferences surrounding labor and delivery?
Anything else you want us to know?
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