Gestational Surrogacy Interest Form

Gestational Surrogacy Interest Form

Formulario de Interés en la Gestación Subrogada
Name / Nombre*

First Name / Nombre de PilaLast Name/ Apellido
Contact Number*
Número de Contacto
Email*
Correo Electrónico
Date of Birth*

MonthDayYear
Fecha de Nacimiento
What is your age today?*
Height*
Altura
Weight*
Peso
Highest level of education obtained. (Nivel más alto de educación alcanzado)*

High School / Título de SecundariaAssociates Degree / Grado AsociadoGraduate Degree / Título de PosgradoPost Graduate Degree / Título de PostgradoOther / Otro
What is your marital status? (¿Cuál es su estado civil?)*

Married / Casado/aMarried but Separated / Casado/a pero Separado/aPartnered (same sex) / En Pareja (mismo sexo)Single (in a relationship) / Soltero/a (en una relación)Single (not in a relationship) / Soltero/a (sin relación)Widowed / Viudo/aDivorced / Divorciado/a
Please list your current and previous place of employment including positions held, dates of employment and locations of each employer:*
Por favor, indique su empleo actual y anteriores, incluyendo los puestos ocupados, las fechas de empleo y las ubicaciones de cada empleador.
If you have a partner or spouse, what is their name?
Si tiene una pareja o cónyuge, ¿cuál es su nombre?
Husband's/Partner's Current Income if applicable:
Ingreso Actual de su Esposo/Pareja, si corresponde:
Your Current Income:*
Su Ingreso Actual:
Please list your husband's/partner's current employment including his positions held and location of employer if applicable:
Por favor, indique el empleo actual de su esposo/pareja, incluyendo los puestos que ha ocupado y la ubicación del empleador, si corresponde.
Are you receiving food stamps or any other public assistance as part of your income? (¿Está recibiendo cupones de alimentos u otra asistencia pública como parte de sus ingresos?)*

Yes / SíNo
How many persons do you support including yourself?*
¿Cuántas personas mantiene, incluyéndose a usted mismo/a?
How many children do you have?*
¿Cuántos hijos tiene?
List the sex of your children and how many of each. State n/a if none.*
What is your Ethnicity?*

American Indian/Alaskan NativeAsianBlack or African AmericanHispanic or LatinaNative HawaiianOther Pacific IslanderWhiteTwo or More Races
Would you like to have any/more children of your own in the future?*

Yes / SíNo
Have you remarried?*

Yes / SíNo
If you have children, are they biologically related to your husband/partner?*

Yes / SíNoNot applicable
What is your citizenship status?*

US CitizenPermanent Resident / Green Card HolderTemporary Resident / Visa HolderI am not a Resident and I do not have a Green Card or Visa
Do you smoke?*

Yes / SíNo
If you do smoke. How many pack per day?
If you do smoke. When did you start?
If you used to smoke. How long did you smoke for?
If you used to smoke. When did you quit?
Do you drink?*

Yes / SíNo
If you drink. How many drinks per day?
If you have hobbies, list them here. If not, state none.*
Have you ever used illegal drugs or un-prescribed drugs?*

Yes / SíNo
If yes, what drugs and how often:
Has your husband/partner used illegal drugs or un-prescribed drugs?*

Yes / SíNo
If yes, what drugs and how often:
Religious background: Practicing*

Yes / SíNo
Preference for the religious background of the intended parents:*

Yes / SíNo
If yes, please specify:
Do you have health insurance?*

Yes / SíNo

List medications you take. State none if none.

NAME	DOSAGE	# PER DAY	REASON

List any allergies you may have. Medication and non-medication - State none if none.*

Pregnancy History

	OWN OR SURROGACY	DATE OF BIRTH	VAGINAL OR C-SECTION	BIRTH WEIGHT	NUMBER OF WEEKS CARRIED
CHILD 1
CHILD 2
CHILD 3
CHILD 4
CHILD 5
CHILD 6

Do you or have your been treated for the following?

	YES OR NO	DATE	TREATMENT	MEDICATIONS	DOSAGE
Anemia
Asthma
Diabetes
Heart Problems
High Blood Pressure
Ovarian Cysts
Migraine Headaches
Uterine Fibroids
Thyroid Problems

Miscarriage / Abortion / Health Problem

CHILD 1
CHILD 2
CHILD 3
CHILD 4
CHILD 5
CHILD 6

Did you have any complications during pregnancy?*

Yes / SíNo
If yes, please note the complication:
Are you currently breastfeeding?*

Yes / SíNo
When was your last pap smear, and what were the results?*

Have you or your partner/spouse ever been diagnosed with

	MYSELF	MY SPOUSE	NEITHER
HIV / AIDS
Chlamydia
Genital Warts
Gonorrhea
Hepatitis C
Herpes
HPV
Syphilis
Trichomoniasis

Surgical History. List any surgeries you have had, when you had them, and the details.*
Have you ever been arrested or convicted of a felony?*

Yes / SíNo
If you have been arrested or convicted of a felony, please provide details.
Would you be willing to work with: (mark all that apply)*

Same sex coupleSingle maleSingle femaleCouple using an egg donorCouple using a sperm donorAn older coupleA couple with childrenAn African American coupleA Jewish coupleA Caucasian coupleAn Indian coupleA Hispanic coupleAn international couple (living outside of the USA)A non-English speaking couple with a translator
Please list the couples you would not be interested in working with, if not listed above.
Have you applied or are you currently applying to be a gestational carrier at any other medical facility, law firm and/or agency?*

Yes / SíNo
If yes, please list:
Have you ever applied to be a gestational carrier at any other medical facility, law firm and/ or agency and been told that you do not meet the facilities’ criteria to be a gestational carrier?*

Yes / SíNo
If yes, please list:
Are you willing to travel for procedure?*

Yes / SíNo
Would you be willing to undergo amniocentesis or other diagnostic testing to determine the presence of birth defects?*

Yes / SíNo
If there were a serious problem with the fetus and the intended parents wanted to abort, would you be willing to abort?*

Yes / SíNo
Are there any specific conditions in which you would not abort a pregnancy?*

Yes / SíNo
Please be specific here and describe in detail under what conditions, if any, you would not be willing to abort?*
Have you gotten a tattoo or any body piercing within the last year and a half?*

Yes / SíNo
If yes, please specify:
Have you ever experienced any postpartum depression?*

Yes / SíNo
If yes, please give the details and time periods:
Have you ever been prescribed or taken any medications for depression or mental health?*

Yes / SíNo
If yes, please list the medications, reason for it and time periods.
Have you ever had any problems with drug or alcohol abuse?*

Yes / SíNo
If yes, please give the details:
Have you ever been advised to have any medical test and/or surgical procedure and failed to take such advice?*

Yes / SíNo
If yes, please explain:
Have your parents had any serious mental or physical illnesses?*

Yes / SíNo
If yes, please explain:
Have you ever been seen by a doctor for infertility?*

Yes / SíNo
Did your mother take DES while pregnant?*

Yes / SíNo
Have you ever been told that you were infertile?*

Yes / SíNo
If either of your parents are deceased what was their age and cause of death?
List any contraceptives you have used in the past and any reaction you had to the use of the contraceptive? If none, state none.*
Which method do you currently use? If none, state none.*
Are you with a sexual partner now?*

Yes / SíNo
If yes, which method does your partner currently use?
Please indicate with whom you have had sexual contact:*

MenWomenBoth
Do you currently have more than one sexual partner?*

Yes / SíNoNo partners currently
How many sexual partners have you had in the past 3 years?*
Have you had sexual contact with a person you do not know well?*

Yes / SíNo
In the past 10 years, have you had sexual contact with anyone in a high risk group for A.I.D.S.? These include sexually active persons with multiple partners.*

Yes / SíNo
To your knowledge have any of your sexual partners been sexually active with anyone in a high risk group for A.I.D.S.?*

Yes / SíNo
Are you at risk for A.I.D.S.?*

Yes / SíNo
Have you ever used IV Drugs?*

Yes / SíNo
Have you ever received a blood transfusion?*

Yes / SíNo
Have you ever had a sexually transmitted disease?*

Yes / SíNo
If yes, please specify:
Have you or a member of your family had a personal experience with any of the following: serious accident or crime, rape, sexual assault, incest or sexual or physical abuse or victim of any crime?*

Yes / SíNo
If yes, please specify:
Current Occupational Status*
Are you currently a member of the US Military?*

Yes, and am currently activeYes, but am no longer activeNo, I've never been a member of the military
Is your partner a member of the US military?*

Yes, but and he/she is no longer activeYes, he/she is active. You will have to provide proof - orders from commanding officer - that you will not have to move for at least 2 yearsNo, he/she has never been a member of the US military
If it were medically necessary to terminate the pregnancy because your health was at risk, would you agree to terminate?*

Yes / SíNo
If it were medically determined that the fetus had Down Syndrome and the intended parents chose to terminate, would you be willing to terminate the pregnancy at their request?*

Yes / SíNo
Are you willing to carry twins?*

Yes / SíNo
Do you exercise?*

Yes / SíNo
Do you take vitamins?*

Yes / SíNo
Do you take illegal drugs?*

Yes / SíNo
Please use this space to provide any additional comments that you would like for us to take note of.
Por favor, use este espacio para proporcionar cualquier comentario adicional que le gustaría que tomemos en cuenta.
How did you hear about NCCRM?

FacebookInstagramPinterestYoutubeTiktokRadio / PodcastSpotifyGoogleEventDoctor ReferralFriend ReferralDirect websiteOther
Please confirm the sate you are in.*
Date*

MonthDayYear
Fecha
By signing here, I state that the detail given in this form is true in correct.*

Clear
Al firmar aquí, declaro que la información proporcionada en este formulario es verdadera y correcta.
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Gestational Surrogacy Interest Form

NAME

DOSAGE

# PER DAY

REASON

OWN OR SURROGACY

DATE OF BIRTH

VAGINAL OR C-SECTION

BIRTH WEIGHT

NUMBER OF WEEKS CARRIED

YES OR NO

DATE

TREATMENT

MEDICATIONS

DOSAGE