Surrogate Application

Surrogate Application

Please complete all the questions in order to be matched as a Gestational Surrogate with a Parent-To-Be. As a Surrogate, you will receive a $45,000-$85,000 Compensation Package with full agency support throughout your surrogacy entire journey and after.
Last Update*

MonthDayYear
Name*

First NameLast Name
E-mail*
Phone Number*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current State of Residence*
Date of Birth*

MonthDayYear
Date
Age
Please enter Height and Weight*
What is your Race and Ethnic Background (e.g. Black/Nigerian or White/German, Asian/Chinese)*
Current Marital Status*

SingleLive with Current PartnerEngagedMarriedMarried but Legally Separated
Occupation and Job Duties*
Do You Have Healthcare Insurance? Please provide the following from you insurance card: Name of Insurance Carrier, Group Number, Member ID and Phone Number to Contact Insurance Carrier.*

Tell Us About Your Pregnancies
What do you enjoy about being pregnant? *

0/1000
How many children have you given birth to? *
How many cesarean births (c-sections) have you had?*

Please tell us about your birth children.

	1st Child	2nd Child	3rd Child	4th Child	5th Child
Age
Gender
Birth Weight
Birth Height
Weeks Born
Any Birth Defects
Any Chronic Diseases
Is Current Partner the Father?
Is this a Surrogacy Birth?

Please tell us about your pregnancies by explaining any condition that occurred below during any of your pregnancies.

	1st Pregnancy	2nd Pregnancy	3rd Pregnancy	4th Pregnancy	5th Pregnancy
Bleeding in Pregnancy
Bed Rest During Pregnancy
Anemia While Pregnant
Diabetes while Pregnant
High Blood Pressure
Preeclampsia (Toxemia)
Low Fluid Around Baby
Extra Fluid Around Baby

Did you experience any of the conditions below during your pregnancies? Please explain.

	1st Pregnancy	2nd Pregnancy	3rd Pregnancy	4th Pregnancy	5th Pregnancy
Water Breaking Early
Thrompocytopenia (low platelets)
Placenta Covering the Cervix
Placenta Tearing Off Early
Placenta Abnormally Attached to Uterus
Cervical Incompetence
Troubling Delivering Baby's Shoulders
Preterm Labor/Contractions

Please explain the circumstance if any apply. Type "NA" the 1st BOX of each row if not applicable.

	Not Applicable	1st Delivery	2nd Delivery	3rd Delivery	4th Delivery	5th Delivery
Induced Abortion
Spontaneous Abortion
Extra Bleeding at Delivery
Trouble Delivering Baby's Shoulders
Medicine to Stop Contractions
Fertility Treatments Used
Still Born
Birth Defects
Birth Difficulties

Have you completed a GYN Exam (Pap Smear) within the past 2 years? If so, what was the name of the Doctor/Practice and what was the result of each exam?

Please tell us about your Gynecological History. If applicable, please explain the circumstance. Type "N" if not applicable.

	Yes	No
Prior Cervical Surgery (LEEP, Cone Biopsy
History of DES exposure
History of abnormal PAP smear
Prior uterine surgery
History of fibroids
History of uterine malformation
History of uterus opening up too early
History of uterine, ovarian or breast cancer

	Syphilis	Gonorrhea	Chlamydia	Genital Herpes
Yes/No

	H.I.V	Hepatitis A	Hepatitis B	HPV
Yes/No

Neurological. Have you or any of your immediate family members (grandparents, aunts/uncles, parents, siblings, children) ever been diagnosed or treated for the following:

	Family Member	Age of Onset	Current Condition	Age of Death (if applicable)
ADD or ADHD
Autism / Asperger's
Learning disabilities
Mental Retardation
Paralysis or crippling disorders
Memory Loss or Dementia
Seizure or Epilepsy
Alzheimer's disease (AD)
Multiple sclerosis
Parkinson's disease
Migraines
Age-related issues

Family History: Have you or any of your immediate family members (grandparents, aunts/uncles, parents, siblings, children) ever been diagnosed or treated for the following:

	Family Member	Date Diagnosed	Treatment Result	Result in Death?
Heart disease
Valve disease
Heart arrhythmia
Heart failure
Enlarged heart
Vascular disease
Hypertension (high blood pressure)
Lung disease
Lung cancer
Pulmonary disease
Asthma
Tuberculosis
Kidney disease
Kidney stones
urinary reflux
Frequent urinary tract infections
Kidney infection
Kidney Failure
Liver disease
Gall bladder cancer

Fun Facts
What was your personality like during each pregnancy?

0/1000
List the things that you enjoyed and that comforted you during your pregnancies:

0/1000

What are your favorite things?

	Most Favorite	Least Favorite
Food
Snack
Ice cream
Restaurant
Leisure Activity
Family Activity
Board Game
Book/Magazine
Movie
TV Show(s)
Music
Song
Band/Artist

Is there anything else you would like to share or feel we should know?

0/1000

Submit Photos

Intended Parents must view photos of you in order to select you as their Surrogate Mother (Gestational Carrier). Uploading photos of your children and a family photo is optional but truly appreciated by Intended Parents and often results in quicker selection. We also recommend you upload photos of yourself while you were pregnant.
Upload Photo of You Looking Directly into the Camera and Smiling
Upload Family Photo
Upload Photo
Upload Pregnancy Photo
Biography: Tell Intended Parents about the type of person you are, your family, your home environment, your support system, your hobbies, and your lifestyle habits. Give them a sense of who you are as a person and a mother.*

CONSENT
I have reviewed my application and agree that I have answered all questions truthfully and to the best of my ability and recollection. I agree to immediately update Diversity Fertility Services, LLC regarding any changes in my complete application including any changes in my medical history, family medical history, education, contact information or availability. *

I agree
I understand that Diversity Fertility Services, LLC will display my anonymous profile (without my name or contact information) and any photographs submitted by me on their online database and in any other medium they determine appropriate, such as email, for the purpose of matching me as a Gestational Surrogate Carrier with an Intended Parent.*

I understand and consent
I understand that the Intended Parent(s) represented by Diversity Fertility Services, LLC, and other professionals involved in the surrogacy process, will rely upon the information contained in my Application and I both understand and agree that I have answered each question completely and truthfully.*

I understand and agree
I understand that it is my responsibility to discuss all medical questions and concerns regarding the surrogacy process with my physician and the IVF clinic with which I will complete the medical process. I also understand that it is my responsibility to discuss all legal questions with legal counsel which will be provided to me for the purpose of the surrogacy process only, at no expense to me.*

I understand and agree
I agree to release Diversity Fertility Services, LLC and hold it harmless from any and all responsibility or liability with respect to any and all risks associated with the legal, medical, and/or psychological aspects of the surrogacy process.*

I understand and agree
I have read the Consent Agreements above and give Diversity Fertility Services permission to use the information I have provided for the purpose of finding, facilitating and coordinating a Gestational Carrier match on my behalf. I understand that my information will remain confidential and will be shared with Physicians, Psychologists, Intended Parents, representatives of medical clinics, legal counsel and any 3rd party directly and indirectly involved in the Gestational Carrier process. I understand and willingly agree to all terms above. *

I understand and agree
Signature

Clear
Thank you for completing our Surrogate Mother Application. Upon selecting the SUBMIT button below, you will receive an email with instructions to log back in and update or complete your application at any time.
Enter the message as it's shown*
Should be Empty:

	Yes	No	Need More Information
Willing to Travel
Willing to Reduce Embryo
Willing to Carry Twins
Willing to Carry Triplets
Willing to Terminate Pregnancy at Intended Parents Request
Willing to Complete an Amniocentesis
Willing to work with International Intended Parents
Willing to work with Single Intended Parent
Willing to work with same sex Intended Parents
Willing to work with Intended Parents of other Races

	Yes	No
Have you ever been hospitalized for mental illness?
Have you ever considered committing suicide?
Have you ever tried to intentionally hurt yourself?
Have you ever tried to hurt a child or baby?
Are you currently in counseling?
Have you ever had an eating disorder?
Have you ever been treated for depression?
Have you ever been treated for anxiety?

	Type of Surgery	Reason for Surgery	Year Completed	Outcome of Surgery
1.
2.
3.
4.
5.

	Date of Procedure	Reason for Procedure	Was procedure completed in a Clinic or OB Office?
1.
2.
3.
4.

	Name of Medication	Dosage	Reason for Taking	Dates Taken
1.
2.
3.
4.
5.
6

Surrogate Application

Surrogacy Experience

Tell Us About Your Pregnancies

Medical History

Fun Facts

Submit Photos

	Yes	Date of Vaccination
Covid-19
Flu
MMR (Measles/Mumps/Rubella)
HPV
Hepatitis C
Hepatitis B
Tetanus
Tuberculosis
Small Pox
Malaria
Diphtheria
Meningococcal
Pneumococcal
Polio
Shingles
Whooping Cough