Surrogate Applicant Name* *
Email* *
Date of Birth* *
Place of Birth*
Primary Phone* *
Other Phone
Address* *
City* *
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* *
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:
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* *
Please list substance and reaction caused:
Please explain:
Please explain: (ex- glasses, contacts)
Please explain:
Please explain:
Please explain:
Please explain if you checked any above and provide dates even if approximate:
Please explain if you checked any above please provide details and dates even if approximate:
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.:* *
List the date(s):
Week:* *
Month:* *
Year:* *
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?)
Approximately how many drinks per week do you consume?*
If you have a significant other/spouse, how much drinks do they consume per week?
Please explain current or former tobacco use. (how often, how much, plans to quit, etc)
Date of last time used/smoked:
Please explain efforts made to avoid exposure to second-hand smoke
Please explain substance use and frequency
Frequency/Year(s)
Frequency/Year(s)
Frequency/Year(s)
Frequency/Year(s)
Frequency/Year(s)
Frequency/Year(s)
Frequency/Year(s)
Frequency/Year(s)
Frequency/Year(s)
Frequency/Year(s)
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. * *
Please explain:
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