• Gestational Surrogacy Interest Form

    Formulario de Interés en la Gestación Subrogada
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Highest level of education obtained. (Nivel más alto de educación alcanzado)*
  • What is your marital status? (¿Cuál es su estado civil?)*
  • 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?)*
  • What is your Ethnicity?*
  • Would you like to have any/more children of your own in the future?*
  • Have you remarried?*
  • If you have children, are they biologically related to your husband/partner?*
  • What is your citizenship status?*
  • Do you smoke?*
  • Do you drink?*
  • Have you ever used illegal drugs or un-prescribed drugs?*
  • Has your husband/partner used illegal drugs or un-prescribed drugs?*
  • Religious background: Practicing*
  • Preference for the religious background of the intended parents:*
  • Do you have health insurance?*

  • List medications you take. State none if none.

    NAME

    DOSAGE

    # PER DAY

    REASON
           
           
           
           
           
           
           

  • 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?*
  • Are you currently breastfeeding?*

  • 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      
  • Have you ever been arrested or convicted of a felony?*
  • Would you be willing to work with: (mark all that apply)*
  • Have you applied or are you currently applying to be a gestational carrier at any other medical facility, law firm and/or agency?*
  • 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?*
  • Are you willing to travel for procedure?*
  • Would you be willing to undergo amniocentesis or other diagnostic testing to determine the presence of birth defects?*
  • If there were a serious problem with the fetus and the intended parents wanted to abort, would you be willing to abort?*
  • Are there any specific conditions in which you would not abort a pregnancy?*
  • Have you gotten a tattoo or any body piercing within the last year and a half?*
  • Have you ever experienced any postpartum depression?*
  • Have you ever been prescribed or taken any medications for depression or mental health?*
  • Have you ever had any problems with drug or alcohol abuse?*
  • Have you ever been advised to have any medical test and/or surgical procedure and failed to take such advice?*
  • Have your parents had any serious mental or physical illnesses?*
  • Have you ever been seen by a doctor for infertility?*
  • Did your mother take DES while pregnant?*
  • Have you ever been told that you were infertile?*
  • Are you with a sexual partner now?*
  • Please indicate with whom you have had sexual contact:*
  • Do you currently have more than one sexual partner?*
  • Have you had sexual contact with a person you do not know well?*
  • 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.*
  • To your knowledge have any of your sexual partners been sexually active with anyone in a high risk group for A.I.D.S.?*
  • Are you at risk for A.I.D.S.?*
  • Have you ever used IV Drugs?*
  • Have you ever received a blood transfusion?*
  • Have you ever had a sexually transmitted disease?*
  • 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?*
  • Are you currently a member of the US Military?*
  • Is your partner 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?*
  • 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?*
  • Are you willing to carry twins?*
  • Do you exercise?*
  • Do you take vitamins?*
  • Do you take illegal drugs?*
  • How did you hear about NCCRM?
  • Date*
     - -
  •  
  • Should be Empty: