Surrogate Applicant Name*
Email* * How did you hear about us?* *
Date of Birth* *
Place of Birth*
Primary Phone* *
State* * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
ZIP Code* * Do you have any American Indian (Native American) ancestry?*
Are you a registered member of an American Indian (Native American) tribe?
If you are married or have a significant other/regular sexual partner, please provide the following information for that person: Name
Is there anyone else over the age of 18 living in your household?
If you are married , please provide their email address:
Emergency Contact Name *
Emergency Contact Relationship to You* *
Emergency Contact Phone* * PERSONAL MEDICAL HISTORY
Height* * Select Option 4 feet 10 inches 4 feet 11 inches 5 feet 0 inches 5 feet 1 inches 5 feet 2 inches 5 feet 3 inches 5 feet 4 inches 5 feet 5 inches 5 feet 6 inches 5 feet 7 inches 5 feet 8 inches 5 feet 9 inches 5 feet 10 inches 5 feet 11 inches 6 feet 6 feet 1 inch 6 feet 2 inches
Weight* * Do you have any allergies?* *
(medicines, food, pollen, etc.)
Please list substance and reaction caused: Do you have normal hearing?* *
Please explain: Do you have normal vision?* *
Please explain: (ex- glasses, contacts) Have you had any (major or minor) operations/surgical procedures?* *
Please explain: Have you ever been hospitalized other than for surgery?* *
Please explain: Have you ever had any serious illness?* *
Please explain: Please check if you've ever experienced any of the following: *
Please explain if you checked any above and provide dates even if approximate: Please check if you've ever experienced any of the following:
Please explain if you checked any above please provide details and dates even if approximate: Have you taken any anti-depressants and/or anti-anxiety medications in the last 12 months?* *
Note: a psychological evaluation is completed on all surrogates
Do you currently take any anti-depressants and/or anti-anxiety medications?* * If you've ever taken anti-depressants and/or anti-anxiety medications please list medication, approximate dates and when you weaned (if applicable)* *
Put N/A if not applicable
List all drugs/medications you currently take including recreational drugs, prescription, nonprescription, vitamins, aspirin, antacids, laxatives, essential oils, herbal & sports supplements, etc.:* *
List all drugs/medications you have taken in the last 12 months including recreational drugs, prescription, nonprescription, vitamins, aspirin, antacids, laxatives, essential oils, herbal & sports supplements, etc.:* * In the preceding 12 months, have you undergone tattooing?* *
*Please note that per FDA guidelines, you will be restricted from obtaining any tattoos, body piercings, or elective cosmetic surgeries throughout the process.
List the date(s):
How many sexual partners have you had sexual activity within the last:
Have you or any of your sexual partners ever had: NSU (non-specific urethritis) - MYSELF* * NSU (non-specific urethritis) - PARTNER* * Venereal warts - MYSELF* * Venereal warts - PARTNER* * Other sexually Transmissible diseases - MYSELF* * Other sexually Transmissible diseases - PARTNER* * Genital Herpes - MYSELF* * Genital Herpes - PARTNER* * Genital Warts - MYSELF* * Genital Warts - PARTNER* * Hepatitis B or C -MYSELF* * Hepatitis B or C - PARTNER* *
Please indicate below whether you currently have, have had in the past, or have ever been treated for: Urinary tract infection* * Renal (kidney) disease* * Skin infections or disease* * Breast lumps or discharge* * Bone or joint problems* * Gastrointestinal problems* * TB (Tuberculosis) or exposure to TB* * High blood pressure (hypertension)* * Tendency to bleed or bruise easily* * Ear infection or problems* * Nose, throat or mouth problems* * Chest problems* *
(e.g., pneumonia, cough, infections)
Recent unexplained weight gain or loss* *
If yes for any of the above, please explain:
In the last year have you traveled outside of the country? If so, where and when?*
Do you have any travel plans in the next 1-2 years? If so, please tell us the destination and approximate time frame:*
Do you have a specific timeline or restrictions for your surrogacy journey? (due to trips, breastfeeding, or personal preference?) Do you drink alcoholic beverages?* *
Approximately how many drinks per week do you consume?*
If you have a significant other/spouse, how much drinks do they consume per week? Do you or have you ever used tobacco products?* *
Please explain current or former tobacco use. (how often, how much, plans to quit, etc)
Date of last time used/smoked: Does anyone in your household use tobacco products?* *
Please explain efforts made to avoid exposure to second-hand smoke Does your spouse/significant other, or anyone in your household use any substances? (ex-marijuana)* *
Please explain substance use and frequency
Have you ever used or do you currently use any of the following drugs?
Frequency/Year(s) Narcotics/Opiates* *
(heroin, methadone, opium, morphine, codeine)
Frequency/Year(s) Please complete information below for each pregnancy you have had:
(Please include ALL pregnancies including miscarriage(s), abortion(s), full-term, etc and type N/A for anything not applicable.)
Please indicate the name and city/state of the clinic and hospital where you intend to go for your surrogate pregnancy?*
What level NICU does this hospital have?*
Distance from home to preferred hospital?*
Which clinic AND hospital did you go to for your previous pregnancies and deliveries? Please list for all pregnancies with city and state. * * Have you discussed becoming a surrogate with the medical provider that you plan to work with throughout your surrogate pregnancy?* * Are you comfortable with the use of injection medications as will likely be required in the process?* *
Please explain: If it were medically determined that the fetus had a chromosomal abnormality or a serious health defect and it did not affect your health, would you allow the Intended Parents to be the ones to make the choice to continue or terminate the pregnancy?* * If found to not be immune to diseases you can receive vaccinations for and that without vaccination, risk is presented to baby, will you undergo those physician-recommended vaccines?* * Many intended parents seek to transfer two embryos either to increase overall success rates or in the hopes of a twin pregnancy and having a two-child family. Would you be willing to undergo a transfer of two embryos? * to see more on our multiples benefit package. Click here
*Please do not contact your insurance company to ask about surrogacy coverage.*
*We will do this investigation on your behalf* to see the CDC guidelines for preventing the spread of COVID-19. Click here
CDC Coronavirus Guidelines
SIGNATURE - I, the undersigned, do hereby swear and affirm that all information contained in this application are true and correct to the best of my knowledge.
* Next Steps
Upon submitting your application, you will be taken to a page to schedule an informational call with us. To qualify for the new Surrogate bonus, you need to have this call within a week. If there are no times available that work for you, please email us to find a time!
You only need to do this call once so if you've already had a call with us prior to completing this application, please disregard.
Any questions? Email us at firstname.lastname@example.org!