Surrogate Mother Application
Identifying Information:
How were you referred to us?
Today's Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
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Bolivia
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Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
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Cote d'Ivoire
Croatia
Cuba
Curacao
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Democratic Republic of the Congo
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Equatorial Guinea
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Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
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Greenland
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Guadeloupe
Guam
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Guinea
Guinea-Bissau
Guyana
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Hong Kong
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India
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Ireland
Israel
Italy
Jamaica
Japan
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Jordan
Kazakhstan
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Kiribati
North Korea
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Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Age
Blood Type
Phone Number (Home)
-
Area Code
Phone Number
Phone Number (Cell)
-
Area Code
Phone Number
Phone Number (Work)
-
Area Code
Phone Number
Occupation
Are you a Florida Resident?
Yes
No
Are you a U. S. Citizen?
Yes
No
Do you have a valid Green Card?
Yes
No
Marital Status:
Single
Married
Divorced
Partner/Non- Marital
If Married, How Long:
Husband's Name:
Husband's Date of Birth:
-
Month
-
Day
Year
Date
Husband's Age:
Husband's Occupation:
Do you have Health Insurance?
Yes
No
If Yes, Name of Health Insurance:
Previous Surrogate?
Yes
No
If Yes, when and what were the results:
PLEASE SUPPLY THREE CHARACTER REFERENCES
(1)Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
-
Area Code
Phone Number
(2) Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
-
Area Code
Phone Number
(3) Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
-
Area Code
Phone Number
Please let us know who you would be willing to work with:
A Married Couple
Yes
No
A Single Woman
Yes
No
A Single Man
Yes
No
A Gay/Lesbian Couple
Yes
No
Please explain why you wish to be a Surrogate Mother:
PHYSICAL CHARACTERISTICS:
Height:
Weight
Do you wear corrective lenses?
Yes
No
If so, for what problem?
Any Hearing Impairment?
Yes
No
If so, please explain
Do you have any tattoos or body piercings?
Yes
No
BACKGROUND:
Race:
Ethnic Origin:
Mother's Race:
Father's Race:
Do you speak any other languages? If yes, please list.
Have you (or your husband/partner) ever been arrested?
yes
no
If yes, Please describe in detail- including the year, circumstances and charges:
What physical activities do you engage in?
Do you have any pets? If so, what kind and how many?
Describe any skills or talents that you have:
EDUCATION
High School Completed
Currently in College; Name of University
Pursuing a Degree in?
Completed College Degree:
Any awards or any non-degree seeking classes taken?
REPRODUCTIVE HEALTH
Age of first period:
Were your cycles regular? If not, please explain:
Interval between periods:
Describe any problems/special circumstances having to do with your reproductive health:
PREGNANCY HISTORY
Please indicate outcome as vaginal, C-section, Ectopic, Miscarriage or Termination
(1)Birth Year
-
Month
-
Day
Year
Date
Outcome
Weeks Gestation
Weight of Baby
Any Complications?
If yes, please explain:
Back
Next
PREGNANCY HISTORY (Continues)
Please indicate outcome as vaginal, C-section, Ectopic, Miscarriage or Termination
(2)Birth Year
-
Month
-
Day
Year
Date
Outcome
Weeks Gestation
Weight of Baby
Any Complications?
(3)Birth Year
-
Month
-
Day
Year
Date
Outcome
Weeks Gestation
Weight of Baby
Any Complications?
(4)Birth Year
-
Month
-
Day
Year
Date
Outcome
Weeks Gestation
Weight of Baby
Any Complications?
(5)Birth Year
-
Month
-
Day
Year
Date
Outcome
Weeks Gestation
Weight of Baby
Any Complications?
CURRENT BIRTH CONTROL METHOD:
For how long?
Back
Next
HEALTH
Do you use nicotine?
cigarettes
vape
other
If yes, duration, type, and daily quantity:
Do you drink Alcoholic beverages?
Yes
No
If yes, How often?
Do now, or have you ever, used mind-altering drugs?
Yes
No
If yes, please explain:
Do you have any medical illnesses?
yes
no
If yes, please explain:
How is your nutrition?
Poor
Average
Good
Excellent
Describe your nutritional habits, likes and dislikes:
Are you a vegetarian?
yes
no
List prescription and non-prescription medications that you take regularly:
Do you have any allergies?
yes
no
If yes, please explain:
Back
Next
MEDICAL HISTORY
Have you had any surgeries?
Yes
No
If yes, please list any surgeries you have had and the dates:
Have you had a blood transfusion?
yes
no
If yes, how long ago?
Have you had major radiation or x-ray exposure?
yes
no
Please describe any other health issues that you have had:
Have you been immunized for:
Diptheria
Polio
Influenza (flu)
Small Pox
Measles, regular
Tetanus
Mumps
Whooping Cough
Rubella
None of the above
Other (please specify below)
Specify any other immunizations you have had:
FAMILY MEDICAL HISTORY
Please read the following list of medical problems carefully and indicate which ones you or one of your relatives have had. Please consider each condition for each family member: HEART AND BLOOD:
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Stroke
Heart Attack
Heart Disease
Hardening of Arteries
High Blood Pressure
Anemia
Sickle Cell
Hemophilia
leukemia
HIV
Other Blood Disease
RESPIRATORY
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Hayfever
Asthma
Emphysema
Tuberculosis
Lung Cancer
Pneumonia
Other Lung Disease
GASTRO INTESTINAL
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Ulcer of stomach or duodenum
Gallstone
Hepatitis A
Hepatatis B
Other Liver Disease
Colon Cancer
Ulcerative Colitis
Crohn's Disease
Cystic Fibrosis
Intestinal Cancer
Other cancer of digestive system
METABOLIC ENDOCRINE
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Diabetes Mellitus
Hypoglycemia
Thyroid Cancer
Thyroid Disease
Goiter
Adrenal Dysfunction or Disorder
Hyperactivity
URINARY
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Kidney Disease
Other Disease of Urinary Tract
Rectal Disorder
GENITAL REPRODUCTION
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Undescended Testicle
Hypospadiasis
Prostate
Uterine Fibroids
Ovarian Cancer
Cancer of Ovaries, Cervis, Uterus
NEUROLOGICAL
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Migraines
Mental Retardation
Senility before age 50
Multiple sclerosis
Cerebral Palsy
Epilepsy
Hydrocephalus
Disorders of the Spinal Cord
Huntington's Chorea
Gaucher's Disease
Wilson's Disease
Other Disease of the Nervous System
MENTAL HEALTH
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Schizophrenia
Manic Depressive
Other mental health problems requiring hospitalization
MUSCULAR, BONES & JOINTS
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Muscular Dystrophy
Other chronic Muscle Disease
Lupus
Deformity of spine
Osteoporosis
Dwarfism
Hereditary Low Back Disease
Arthritis
Gout
Back
Next
PSYCHO/SOCIAL:
Religion:
What Religion were you born into?
What Religion are you now?
Are you an Atheist?
Yes
No
Are you an Agnostic?
Yes
No
How Religious are you now?
Very
Moderately
Occasionally Attend
Not at all
Please give a brief description of yourself and your personality:
**PLEASE ATTACH A FEW PICTURES OF YOU AND OF YOU AND YOUR FAMILY**
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