Surrogate Application Become a Surrogate 1CONTACT INFORMATION2BACKGROUND INFORMATION3Personal Characteristics4Medical History5Personal Characteristics Surrogate Name* Email* Mailing address* City, State ZIP* Phone number*Best Time to Contact*Best Time to Contact*AMPMWeekends Only Date of Birth* MM slash DD slash YYYY Have you ever been a surrogate?*ChoicesYesNoIf, so when?*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Present Employer Present Occupation Marital Status*ChoicesSingleMarriedDivorcedIf married, how long have you been together?* Spouse Name* Spouse Birth Date* MM slash DD slash YYYY Spouse’s Employer* Spouse’s Occupation* Have you or your spouse ever?* Filed Bankruptcy Been turned down by an adoption agency Been past due on child support Been in a substance abuse program Have current legal cases or claims pending None of the above Have you ever been convicted of a crime?* Yes No Height* Weight* Is your bone structure*ChoicesSmallMediumLargeWhat is the highest level of education that you have attained?*ChoicesHigh School GraduateSome CollegeCollege GraduateAdvanced DegreeWhat is your religion?* Do you practice?*ChoicesYesNoWhat is your race? (Check All that Apply)* White Black Hispanic/Latino Asian Hawaiian/Pacific Islander American Indian/Alaska Native Insurance InformationInsurance Carrier* Effective Date* MM slash DD slash YYYY Name of Primary Insurance Holder* How many successful pregnancies have you had?*Choices0123456789How many miscarriages have you had?*Choices012345678910Have you ever had a stillbirth?*ChoicesYesNoIf, so when?*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pregnancy #1Child’s first name* First Child's Gender*ChoicesFemaleMaleDate of Birth* MM slash DD slash YYYY Full term?*ChoicesYesNoBirth Weight* Birth Delivery*ChoicesC-SectionVaginal BirthWeeks at Delivery*ChoicesEarlier than 37 weeksMore than 37 weeksComplications:*Pregnancy #2Child’s second name:* First Child's Gender*ChoicesFemaleMaleDate of Birth* MM slash DD slash YYYY Full term?*ChoicesYesNoBirth Weight* Birth Delivery*ChoicesC-SectionVaginal BirthWeeks at Delivery*ChoicesEarlier than 37 weeksMore than 37 weeksComplications:*Pregnancy #3Child’s third name:* First Child's Gender*ChoicesFemaleMaleDate of Birth* MM slash DD slash YYYY Full term?*ChoicesYesNoBirth Weight* Birth Delivery*ChoicesC-SectionVaginal BirthWeeks at Delivery*ChoicesEarlier than 37 weeksMore than 37 weeksComplications:*Pregnancy #4Child’s fourth name:* First Child's Gender*ChoicesFemaleMaleDate of Birth* MM slash DD slash YYYY Full term?*ChoicesYesNoBirth Weight* Birth Delivery*ChoicesC-SectionVaginal BirthWeeks at Delivery*ChoicesEarlier than 37 weeksMore than 37 weeksComplications:*Pregnancy #5Child's fifth name* Child's Gender*ChoicesFemaleMaleDate of Birth* MM slash DD slash YYYY Full term?*ChoicesYesNoBirth Weight* Weeks at Delivery*ChoicesEarlier than 37 weeksMore than 37 weeksComplications:*Pregnancy #6Child's sixth name* Child's Gender*MaleFemaleDate of Birth* MM slash DD slash YYYY Full term?*ChoicesYesNoBirth Weight* Weeks at Delivery*ChoicesEarlier than 37 weeksMore than 37 weeksComplications:*Pregnancy #7Child's seventh name* Child's Gender*MaleFemaleDate of Birth* MM slash DD slash YYYY Full term?*ChoicesYesNoBirth Weight* Weeks at Delivery*ChoicesEarlier than 37 weeksMore than 37 weeksComplications:*Pregnancy #8Child's eighth name* Child's Gender*MaleFemaleDate of Birth* MM slash DD slash YYYY Full term?*ChoicesYesNoBirth Weight* Weeks at Delivery*ChoicesEarlier than 37 weeksMore than 37 weeksComplications:*Pregnancy #9Child's ninth name* Child's Gender*MaleFemaleDate of Birth* MM slash DD slash YYYY Full term?*ChoicesYesNoBirth Weight* Weeks at Delivery*ChoicesEarlier than 37 weeksMore than 37 weeksComplications:*Did you need medical assistance in achieving a pregnancy?*ChoicesYesNoDid you take more than 6 months to conceive your child(ren)?*ChoicesYesNoWhat is your current method of birth control?* Are your menstrual cycles regular?*ChoicesYesNoIs there family history of fertility problems in your family?*ChoicesYesNoWhat is your daily activity level?*ChoicesSedentaryModerately activeHighly activeWhat do you eat on a typical day?*Do you smoke?*ChoicesYesNoDoes anyone in your household smoke?*ChoicesYesNoAre you on any prescription medications?*ChoicesYesNoIf yes, please indicate which ones and the reason:* Do you take any non-prescription drugs?*ChoicesYesNoIf yes, please indicate which ones and the reason:* Have you been vaccinated against Hepatitis B?*ChoicesYesNoHave you been vaccinated against COVID-19?*ChoicesYesWill be getting vaccineNot getting vaccineDo you drink alcohol?*ChoicesYesNoHow often?*ChoicesSeldomOccasionalRegularlyHave you ever abused alcohol?*ChoicesYesNoDo you or have you ever used illegal drugs?*ChoicesYesNoHave you ever had to receive psychological counseling (including substance abuse counseling, marriage or family therapy)?*ChoicesYesNoIf yes, please explain:* Have you ever been under the care of a psychiatrist?*ChoicesYesNoIf yes, please explain:* Please list any significant illnesses you have had:*Have you had or currently have any of the following conditions:* Bleeding or Clotting Disorders Cancer Diabetes High blood pressure Gestational diabetes Preeclampsia Hepatitis Seizure Disorder Liver Disease Kidney Failure Thyroid Disease None Have you ever had surgery?*ChoicesYesNoIf yes, please explain:* Have you ever been hospitalized other than listed?*ChoicesYesNoHave you ever had major radiation or x-ray exposure?*ChoicesYesNoHave you ever had any jobs, hobbies, or activities that could have exposed you to chemicals, drugs, or gasses?*ChoicesYesNoWhen was your last physical exam?Month*MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Primary Care Physician Address:* When was your last pap smear?Month*MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Were the results normal?*ChoicesYesNoOBGYN Address:*Have you or your partner had any sexually transmitted diseases?*ChoicesYesNoIf yes, please specify:* Have you ever donated blood or had a blood transfusion?*ChoicesYesNo Describe your personality:*What kinds of hobbies or activities do you enjoy?*Please describe your future goals (personal and career):*How do you manage stress in your life (particularly to periods that you have been pregnant)?*Surrogacy InformationHave you applied to any other programs to be a surrogate?*ChoicesYesNoAre you willing to travel to another state for an embryo transfer procedure? (We only work with US clinics. All travel costs are fully covered by your Intended Parents).*ChoicesYesNoAre you willing to work with Intended Parents that live in another state?*ChoicesYesNoAre you willing to work with Intended Parents that live internationally?*ChoicesYesNoBriefly explain your personal reasons for wanting to be a surrogate:*What qualities do you consider to be most important in choosing to work with prospective parents?*Open to matching with: ( Check all that apply )* Married couple Partners Single Person LGBTQ As a surrogate, would you have any concerns with the prospective parents participating in the birthing process?*ChoiceYesNoHow do you feel being a gestational surrogate will affect your life? How might it prove difficult?*How much contact would you like with the parents during pregnancy, delivery and after the child is born?*During the surrogacy process, who can you expect to receive emotional support from?*Is your partner aware of their responsibilities in the medical process and are they willing to cooperate (such as abstinence, testing)?*ChoicesYesNoWhat are your biggest concerns about becoming a gestational surrogate?*Would you consent to prenatal testing for birth defects?*ChoicesYesNoAre you open to selective reduction in the event of high-order multiples?*ChoicesYesNoAre you open to termination in the case of a major medical issue or significant congenital malformation resulting in little or no life expectancy for the fetus?*ChoicesYesNoAre you open to termination in the event of a Down Syndrome diagnosis?*ChoicesYesNoAre you open to termination in the event of a chromosomal abnormality other than Down Syndrome?*ChoicesYesNoHow many transfer attempts would you feel comfortable with in order to become pregnant?* 1 2 3 4+ How many embryos are you open to transferring?*ChoicesOnly 1 embryo at a timeOpen to 2 embryos being transferred Δ
