SM Application

Name:

E-mail:

Full Address:

Phone

Cell Phone:

Work Phone:

Where did you hear about RM?

Myspace/Facebook:

Application Type:

Have you ever been a surrogate before?

If yes, please describe your experience and the result:

Would you be willing to reduce the number of fetuses if asked?

Maximum number of fetuses you would carry:

How do you feel about termination?

How much compensation do you think is fair and reasonable for a surrogate of your type, experience, and background?

What is your current height?

What is your current weight?

Have you had your tubes tied?

What is your current method of birth control?

When were you last tested for HIV? Result?

When were you last tested for other STD? Results?

Please describe and give dates for any surgeries or major illnesses:

For each of your children list the following: name, year of birth, birth weight, gesational age at delivery, and delivery method:

Have you ever had any abortions, miscarriages, or still births? Please give appx dates:

Have you ever received fertility treatments in order to become pregnant?

Please describe any difficulies women in your family have had getting pregnant or carrying a pregnancy to term:

Please describe any pregnancy/delivery complications, illnesses, difficulties:

RH +/-

Are you a carrier of cystic fibrosis?

Do you follow a special diet like vegetarianism, veganism, etc? Please explain:

Date of Birth

MonthDayYear

Have you given birth to at least one healthy child?

Are all of your children in your custody?

Do you have reliable transporation?

Are you currently receiving any of the following? Check all that apply:

Are you taking antidepressants?

Do you smoke or use any tobacco products?

Do you drink alcoholic beverages?

Have you ever been charged with domestic violence, child endangerment, or any form of assult or battery?

Have you ever been charged with a crime related to the use, posession, sale, or transport of drugs or drug paraphernalia

Have you ever been charged with a crime involving theft, fraud, or similar?

Did you graduate from high school?

Did you go to college?

If you received a degree, what was the degree?

Tell us abou what you do for a living:

What are your professional goals and do you see surrogacy helping you reach them?

How will being pregnant affect your work?

Are you married?

Partner's Name:

How long have you been together?

How did your partner react to the idea of surrogacy or what do you think the reaction will be when you do tell them?

How did your children react when you told them about your plan to be a surrogate?

How will your obligations as a surrogate affect your family and their schedules (work, child care, school, etc)?

Check ALL family types you would consider:

Is there any family type not listed above that you would be unwilling to work with?

Please use this area to write a letter to prospective parents telling them about yourself:

If you have any questions for RM staff, list them here. We will answer them during your interview.

Select a date for your intake interview using the calendar tool provided:

MonthDayYearHourMinutesAM/PM Option

What time, on this day, should we plan to call?

Enter the phone number for us to call for this interview:

I understand that I will be required to pass a drug test before my application can be approved.

I understand that I will be required to submit to a criminal background check before my application can be approved.

I understand that I will be required to release certain medical records to RM staff relating to my previous pregnancies before my application can be approved.

I am aware that before I can proceed with a potential match, I will be required to undergo a psychological evaluation and a physical exam conducted by the fertility clinic.

I am aware that if I am living with a romantic partner, he or she will be subject to some of the same screening measures listed above.

Face Photo:

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Full Length Photo:

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Another Photo:

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Family/Children Photo:

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Contact Info:

Surrogacy Questions:

Health History:

Applicant Info:

Work & Family:

Closing Notes: