Surrogacy Pre-Qualification Application
Please fill each question out with as much information as you can provide. Please be open and honest. We will contact you after we review your pre-qualification application. If you have any questions, please call Alisha or Nicole at 208-297-5189 or email us at surrogacy@hostofpossibilities.com
General Information
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Age
*
What is your height?
*
Your current height and weight is important in determining your BMI.
What is your current weight?
*
Your current height and weight is important in determining your BMI.
Are you a U.S. citizen?
Yes
No
What city do you live?
*
In what state do you live?
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Do you work outside the home?
*
Yes
No
How did you hear about us?
*
Craigslist
FindSurrogateMother.com
Google
Referral
Facebook
Family
Relationship Status (please select all that apply)
*
Married
Divorced
Single
Live-in Partner
Dating
How many pregnancies have you had resulting in a live birth?
*
How many pregnancies have you had resulting in a miscarriage, or still birth?
*
How have your pregnancies been: full term? vaginal? any C-sections? any complications?
*
What is your current method of birth control?
*
Pill
IUD
Patch or Shot
Tubal Litigation
Partner has Vasectomy
Abstinence
Date of last PAP:
*
American Society for Reproductive Medicine Guidelines
Please answer truthfully to all questions. Just because you answer yes to one question doesn't mean you will be disqualified. It's more important that you are open and honest with all your answers.
Do you have health insurance?
*
Yes
No
Do you currently receive any government assistance (food stamps, section 8 housing, Medicaid, etc)?
*
Yes
No
Do you and/or your partner have a criminal background (misdemeanors, felonies, arrests)? If yes, please explain.
*
Do you have any pre-existing medical conditions that you have every been diagnosed with? If yes, please explain.
*
Do you take any prescription medications on a daily basis? If so, please list the name and dose of the medication.
*
Have you ever been diagnosed with any of the following? (depression, anxiety, PTSD, bipolar, etc.)? If yes please explain: what was the diagnosis? at what age? are you taking medication?
*
Have you received the Covid-19 vaccine?
*
Yes
No
Are you willing to receive the Covid-19 vaccine?
*
Yes
No
Have you ever been treated for drug or alcohol abuse?
*
Yes
No
Do you currently use any tobacco or vape products?
*
Yes
No
If you do use tobacco/vape products, did you use them during your pregnancies?
Yes
No
Does your partner currently use tobacco or vape products?
Yes
No
Do you have reliable transportation to get yourself to and from medical appointments?
*
Yes
No
Preferences
We have a wide variety of couples and individuals looking to start their family with your help. Please think about who you would be comfortable carrying for. (If you qualify, you can always change your mind later.)
Would you carry for a...(please select all that apply)
*
Heterosexual Couple
Same Sex Couple
Single Dad
Single Mom
International Couple or Individual
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