Prospective Surrogate Questionnaire - IARC Surrogacy

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Welcome to IARC Surrogacy!

Get started today by filling out this short Quick Start Questionnaire!

First Name* *

Last Name* *

Email* *

How did you hear about IARC?* *

Best number to reach you* *

Date of Birth* *

State* *

Height* *

Weight* *

Are you raising at least 1 child in your home?* *

Yes

No

Please list dates of birth of your children.

Tobacco Use* *

No

Daily

Weekly

Occasional

Former User

Please list any criminal history (including DUI, minor, etc.)* *

*Note: a criminal background check is completed on all surrogates

Do you receive any of the following financial assistance? Click all that apply.* *

Food Stamps

Medicaid (state insurance)

Cash Assistance/Welfare

WIC

SSI/SSDI

Public Housing

Other

None

.

Medical History

How many pregnancies have you had (including miscarriages & abortions)* *

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

First Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Second Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Third Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Fourth Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Fifth Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Sixth Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Seventh Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Eighth Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Ninth Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Tenth Pregnancy

Have you had any pregnancy/delivery/postpartum complications or things to note that may affect your chances of approval with clinics? If so, please explain: *

Please select any STDs you have had, if any:* *

None

Gonorrhea

Chlamydia

Herpes

HPV

Syphilis

Hepatitis B

Hepatitis C

OtherOther

Please check if you experience any of the following:* *

Anxiety

Depression

PTSD

Post-Partum Depression

Bipolar Disorder

None

Please explain if you checked any above:

List all anti-depressants and/or anti-anxiety medications you have taken with approximate dates and when you weaned (if applicable)

Please list any supplements, vitamins, or medications you are currently taking or have taken in the last 12 months (with approx. dates):* *

What is your interest level in becoming a surrogate?* *

Interested in gathering information

Very Interested

Maybe someday in the future

By submitting this questionnaire, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted to the Gestational Carrier candidate list, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.* *

Agree

Signature of Prospective Surrogate* *

Use your mouse or finger to draw your signature above.

Next Steps

We will email you within 1 business day once we review your questionnaire . Please check your spam folder if you do not hear from us.

Upon submitting your questionnaire, you will be taken to a page to schedule your informational call with us. Any questions? Email [email protected]

If you are human, leave this field blank.

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