SURROGATE APPLICATION

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Full Surrogate Application

EDUCATION

EMPLOYMENT

(e.g. number of days of leave before policy kicks in, what percent is paid, how many days/weeks apply to maternity leave?)

PERSONAL MEDICAL HISTORY

(medicines, food, pollen, etc.)
Note: a psychological evaluation is completed on all surrogates
*Please note that per FDA guidelines, you will be restricted from obtaining any tattoos, body piercings, or elective cosmetic surgeries throughout the process.

 

How many sexual partners have you had sexual activity within the last:

 

Have you or any of your sexual partners ever had:

 

Please indicate below whether you currently have, have had in the past, or have ever been treated for:

(e.g., pneumonia, cough, infections)

 

Have you ever used or do you currently use any of the following drugs?

(heroin, methadone, opium, morphine, codeine)

GYNECOLOGIC HISTORY

# of days from beginning of one cycle to the beginning of the next (naturally, not on birth control):
(# of days)
*We recommend using multiple methods if no permanent sterilization from this point on*


PREGNANCY HISTORY

Total Number of Pregnancies (please fill in the number for each applicable box below):

 

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.)

 
 

MEDICAL INSURANCE

Drop a file here or click to upload Choose File
Maximum upload size: 10MB

*Please do not contact your insurance company to ask about surrogacy coverage.*
*We will do this investigation on your behalf*