Surrogate Application

G.C. Applicant Name* *

How did you hear about us?* *

Marital Status* *

If you are married or have a significant other/regular sexual partner, please provide the following information for that person:
Name

Your Street Address* *

City*

State

ZIP Code* *

Primary Phone* *

Other Phone

Email* *

Alternate Email

Date of Birth* *

Place of Birth* *

Social Security Number* *

Race* *

Do you have any American Indian (Native American) ancestry?* *

Yes

No

Are you a registered member of an American Indian (Native American) tribe?

Religion* *

EDUCATION

What was/is your field of study?

EMPLOYMENT

Current occupation* *

Current employer* *

Employment start date with this employer

How often do you receive a paycheck?* *

What is the net amount per paycheck?* *

What is your monthly household income?* *

Flexibility to take time off with notice?* *

Yes

No

Do you have a short-term disability policy?* *

Yes

No

If you know the terms of your short-term diability policy, please list details:

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

Have you ever been convicted of a crime (including DWI & DUI)?* *

Yes

No

Please explain with approximate dates:

PERSONAL MEDICAL HISTORY

Blood Rh factor* *

Positive

Negative

Unknown

Height* *

Weight* *

Do you have any allergies?* *

Yes

No

(medicines, food, pollen, etc.)

Please list substance and reaction caused:

Do you have normal hearing?* *

Yes

No

Please explain:

Do you have normal vision?* *

Yes

No

Please explain:

Have you had any (major or minor) operations/surgical procedures?* *

Yes

No

Please explain:

Have you ever been hospitalized other than for surgery?* *

Yes

No

Please explain:

Have you ever had any serious illness?* *

Yes

No

Please explain:

Please explain if you checked any above:

Have you taken any anti-depressants and/or anti-anxiety medications in the last 6 months?* *

Yes

No

Note: a psychological evaluation is completed on all surrogates

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?* *

Yes

No

*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:

Week:* *

Month:* *

Year:* *

Have you or any of your sexual partners ever had:

NSU (non-specific urethritis) - MYSELF* *

Yes

No

NSU (non-specific urethritis) - PARTNER* *

Yes

No

Chlamydia - MYSELF* *

Yes

No

Chlamydia - PARTNER* *

Yes

No

Venereal warts - MYSELF* *

Yes

No

Venereal warts - PARTNER* *

Yes

No

Syphilis - MYSELF* *

Yes

No

Syphilis - PARTNER* *

Yes

No

Gonorrhea - MYSELF* *

Yes

No

Gonorrhea - PARTNER* *

Yes

No

Herpes - MYSELF* *

Yes

No

Herpes - PARTNER* *

Yes

No

Other sexually Transmissible diseases - MYSELF* *

Yes

No

Other sexually Transmissible diseases - PARTNER* *

Yes

No

HPV - MYSELF* *

Yes

No

HPV - PARTNER* *

Yes

No

Genital Herpes - MYSELF* *

Yes

No

Genital Herpes - PARTNER* *

Yes

No

Genital Warts - MYSELF* *

Yes

No

Genital Warts - PARTNER* *

Yes

No

Hepatitis B or C -MYSELF* *

Yes

No

Hepatitis B or C - PARTNER* *

Yes

No

HIV - MYSELF* *

Yes

No

HIV - PARTNER* *

Yes

No

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

Blood transfusion* *

Yes

No

Kidney stones* *

Yes

No

Urinary tract infection* *

Yes

No

Renal (kidney) disease* *

Yes

No

Psychiatric disorders* *

Yes

No

Heart problems* *

Yes

No

Eye problems* *

Yes

No

Skin infections or disease* *

Yes

No

Breast lumps or discharge* *

Yes

No

Bone or joint problems* *

Yes

No

Gastrointestinal problems* *

Yes

No

TB (Tuberculosis) or exposure to TB* *

Yes

No

Cancer* *

Yes

No

High blood pressure (hypertension)* *

Yes

No

Diabetes* *

Yes

No

Tendency to bleed or bruise easily* *

Yes

No

Neurological disorder* *

Yes

No

Headaches, dizziness* *

Yes

No

Ear infection or problems* *

Yes

No

Nose, throat or mouth problems* *

Yes

No

Chest problems* *

Yes

No

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

Back problems* *

Yes

No

Recent unexplained weight gain or loss* *

Yes

No

Blood clots* *

Yes

No

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 drink alcoholic beverages?* *

Yes

No

Which kinds?*

Beer

Wine

Liquor

Approximately how many drinks per week do you consume?*

Do you or have you ever used tobacco products?* *

Yes

No

Please explain current or former tobacco use. (how often, how much, plans to quit, etc)

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

Marijuana* *

Yes

No

Frequency/Year(s)

Cocaine* *

Yes

No

Frequency/Year(s)

Barbiturates* *

Yes

No

Frequency/Year(s)

Narcotics/Opiates* *

Yes

No

(heroin, methadone, opium, morphine, codeine)

Frequency/Year(s)

Amphetamines* *

Yes

No

Frequency/Year(s)

Hallucinogens* *

Yes

No

Frequency/Year(s)

Tranquilizers* *

Yes

No

Frequency/Year(s)

PCP* *

Yes

No

Frequency/Year(s)

Inhalants* *

Yes

No

Frequency/Year(s)

Steroids* *

Yes

No

Frequency/Year(s)

GYNECOLOGIC HISTORY

# of days from beginning of one cycle to the beginning of the next (naturally, not on birth control):

Average # of days* *

Range of days:* *

Length of menstrual flow:* *

(# of days)

Amount of flow:* *

Light

Moderate

Heavy

First days (dates) of last TWO menstrual periods:* *

Describe any menstrual problems:* *

Describe any vaginal discharge or irritation:* *

Date of most recent Pap smear:* *

Have you ever had an abnormal Pap smear?* *

Yes

No

Have your subsequent Pap smears been normal?* *

Yes

No

Describe any difficulty with intercourse* *

Do you have problems with pelvic pain, infections, endometriosis, etc?* *

If Birth Control Pills/Patch, how long have you been taking/using them?

If Depo-Provera when was your last injection?

PREGNANCY HISTORY

Have you ever undergone treatments related to infertility or surrogacy previously?* *

Yes

No

Please explain:* *

How many children do you have?* *

Are you currently breastfeeding and/or pumping?* *

Yes

No

When do you anticipate weaning and ending?

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

Confirmed

Living Children

Full-Term

Premature

Stillborn

Miscarriage

Ectopic

Elective Abortion

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.)

Gender* *

Male

Female

Date of Birth

Gestation at Delivery* *

Birth Weight* *

Months to Conceive* *

Miscarriage or Abortion?

Yes

No

Problems or Complications?* *

Cesarean or Vaginal?* *

Cesarean

Vaginal

N/A

+ ADD ANOTHER PREGNANCY

- REMOVE

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?* *

Which clinic and hospital did you go to for your previous pregnancies and deliveries? Please list for all pregnancies with city and state. (ex- 2014- Allina Health Clinic in Hopkins, MN; 2014- Abbott Northwestern Hospital in Minneapolis, MN)* *

Have you discussed becoming a surrogate with the obstetrician or physician that you plan to work with throughout your surrogate pregnancy?* *

Yes

No

Are you comfortable with the use of injection medications as will likely be required in the process?* *

Yes

No

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?* *

Yes

No

Would like to discuss further

MEDICAL INSURANCE

Do you have medical insurance?* *

Yes

No

Name of insurance company

Monthly premium

Effective date of coverage

May our agency contact your insurance company to verify details of your insurance coverage?* *

Yes

No

If you have a copy of your insurance card and/or booklet, please upload it here

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*

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.

* *

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EDUCATION

EMPLOYMENT

PERSONAL MEDICAL HISTORY

GYNECOLOGIC HISTORY

PREGNANCY HISTORY

Please complete information below for each pregnancy you have had:

MEDICAL INSURANCE

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