Surrogate Mother Confidential Registration
Type of Contact
Name
*
First Name
Last Name
E-mail
*
Phone Number
Format: (000) 000-0000.
Please select your State to ensure you live in a surrogacy friendly area within the United States of America.
*
Select State
California
Colorado
Connecticut
Delaware
District of Columbia
Hawaii
Illinois
Maine
Maryland
Massachusetts
Minnesota
Nevada
New Hampshire
New Jersey
New Mexico
North Dakota
Oregon
Pennsylvania
Rhode Island
Utah
Vermont
Washington
Wisconsin
How did you hear about our agency? Please list the name of your referral source (clinic, friend, case manager, recruiter, advertisement, website, media article, etc..)
*
Do you have a healthy uterus, and do you get a regular menstrual cycle every month?
*
Yes
No
Have you given birth to one or more healthy children?
*
Yes
No
Other
Have you had 3 or more Cesarean deliveries (C-sections)
*
Yes
No
Have you ever experienced any complications during any of your pregnancies?
*
Yes
No
If Yes, please explain
Are you a U.S. or Canadian Citizen or Permanent Resident?
*
Yes
No
Have you ever been diagnosed Endometriosis, Fibroids or Infertility?
*
Yes
No
Have you used Tobacco or Nicotine in any form within the past 6 months? (Select YES if you smoke cigarettes, use E-Cigs, Hookah, Nicotine Patch or chew tobacco)
*
Yes
No
If Yes, please explain
Have you or your partner used any of these prescription or recreational drugs in any form within the past 6 months? Please select the name of the medication used. Select "Not Applicable" if you have not used any of these medications.
*
Please Select
Cocaine
Heroine
Morphine
Ecstasy or Molly (MDMA)
Ritalin (Methylphenidate)
Xanax (Alprazolam)
Vicodin (Hydrocodone)
Adderall (Amphetamine)
OxyContin (Oxycodone)
Clonazepam (Klonopin)
Valium (Diazepam)
Ambien (Zolpidem)
Methadone
LSD
DMT
Methamphetamine
Soma (Carisoprodol)
Ketamine
Oxymorphone
Buprenorphine
Ativan (Lorazepam)
Not Applicable
Have you ever been convicted of a misdemeanor? (Example DUI, DWI, Theft, Possession, etc..)
*
Yes
No
If Yes, please explain
Have you ever been convicted of a Felony?
*
Yes
No
If Yes, please explain
Have you ever been in juvenile detention, lockup, jail, or prison for more than 72 hours?
*
Yes
No
Have you or any of your sexual partners ever tested positive for HIV/AIDS, Hepatitis B or Hepatitis C?
*
Yes
No
Have you or a sexual partner ever been infected with or treated for either the Ebola virus or the Zika virus?
*
Yes
No
Not sure
Have you ever been diagnosed with a psychological disorder such as Acute Anxiety, Depression, Schizophrenia, Bipolar and Related Disorders, PTSD, Autism Spectrum Disorder, Attention Deficit Disorder, and Dissociative Disorder?
*
Yes
No
Are you now taking or have you EVER taken any of these medications: Propecia© (finasteride) Accutane© (Amnesteem, Claravis, Sotret, isotretinoin) Soriatane© (acitretin) Tegison© (etretinate) Growth Hormone Insulin Hepatitis B Immune Globulin Unlicensed Vaccine usually associated with a research protocol
*
Yes
No
Have you ever had: (i). Any type of cancer, including leukemia; (ii). Any problems with your heart or lungs; (iii). A bleeding condition or a blood disease; (iv). Sexual contact with anyone who was born in or lived in Africa; (v). Received a dura mater (or brain covering) graft; (vi) Have any of your relatives had Creutzfeldt-Jakob disease?
*
Yes
No
In the past 12 months, have you or any sexual partner had contact with anyone that has (please select ALL that apply):
*
Not Applicable
Had HIV/AIDS or tested positive for the HIV/AIDS virus?
Takes money or drugs or other payment for sex?
Hemophilia or has used clotting factor concentrates?
Has Hepatitis?
Ever used needles to take drugs or steroids, or anything not prescribed by their doctor?
Had sexual contact with a male who has ever had sexual contact with another male?
Submit
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