Become a Surrogate

Qualifications - Step 1 of 4

Qualifications

Name *

First

Last

Birthdate *//

Layout

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

What is your preferred method of contact? *

Cell Phone
Home Phone
Email
Text

How did you hear about our program? *

Google
Facebook
Instagram
Twitter
Referral
I am a previous surrogate
Doctor
Other ad

How soon are you ready to become a surrogate? *

Right Away
3-6 months
6+ months
Still Researching
Undecided

Residency/Citizenship Status *

US Citizen
Non-US Citizen with permanent residency or valid green card
Non-US Citizen without green card
DACA with work permit
DACA without work permit

Have you given birth to at least one child? *

Have you had a healthy full term pregnancy and delivery? *

How many children do you have? *

Is your BMI (Body Mass Index) 32 or below? *

What is your current weight in pounds? *

What Is Your Height in Feet & Inches? *

First

Last

What is your expected base compensation? *

Do you have a valid driver's license? *

Are you vaccinated for COVID-19? *

If not, are you willing to be vaccinated for COVID-19? *

Medical History

Last Period? How many days? *

What is your current method of birth control? *

Oral contraceptive pill
IUD
Condoms
Depo provera shot
Arm implant
Abstinence
Tubal ligation/ tubes tied
Essure
Partner's vasectomy
Other
None

What was the date of your last Pap smear? *

Was the result normal? *

Do you have any medical problems? If so, please describe what problems you have? *

What is your blood type? *

Are you currently taking any medications? If so, which medications and why do you take it? *

Please indicate any current allergies you have to food, medicine etc. *

Do you or anyone in your family have a history of drug or alcohol abuse? *

Have you ever been diagnosed with any of the following sexually transmitted infections? *

Chlamydia
Venereal warts
Herpes
HIV
Other
None

Have you ever been diagnosed with any of the following health conditions? *

Hypertension
Seizure Disorder
Cancer
Blood Clotting
Diabetes
Heart Defects
None

Have you ever been diagnosed with any of the following mental health conditions: *

Bipolar Disorder
Anxiety
Depression
Postpartum Anxiety/Depression
Schizophrenia
Obsessive Compulsive Disorder
Attention Deficit Hyperactive Disorder (ADHD)
Self-Harming
Other
None

Have you had any surgeries? If so, please share what kind and month/year? *

Do you wear corrective lenses (contacts or glasses)? *

Do you have a history of intravenous drug use? *

Has your lifestyle in any way put you at risk for AIDS/HIV? *

Please explain when and if it was treated *

Has anyone in your family ever been diagnosed with any of the following mental health conditions: *

Nervous Breakdown
Bipolar Disorder
Depression
Anxiety
Postpartum Anxiety/Depression
Schizophrenia
Obsessive Compulsive Disorder
Attention Deficit Hyperactive Disorder (ADHD)
Self-Harming
Other
None

Have you ever undergone psychotherapy or counseling with a mental health professional? *

Do you use tobacco or cannabis products? Smoke, vape, marijuana, cigarettes, etc. *

Are you exposed to secondhand smoke in your household? *

Do you consume alcoholic beverages? If so, how often? *

How frequently do you exercise? *

What types of exercise do you do? *

Weights
Running
Walking
Swimming
Dance
Gym
Hiking
Sports
Other

Pregnancy History

Have you ever had a miscarriage? *

Have you ever had an abortion or terminated a pregnancy? *

How would you describe your overall experience w/pregnancy? *

Did you breastfeed your own child(ren), if so, how long? *

Add a pregnancy #1

Add a pregnancy

Name of Child *

Sex *

Male
Female

Birthdate *//

Birthweight *

Weeks of gestation at delivery *

Vaginal Birth or C-Section *

Vaginal Birth
C-Section

Any complications? *

Was this a surrogate pregnancy? *

Add a pregnancy #2

Add a pregnancy

Name of Child *

Sex *

Male
Female

Birthdate *//

Birthweight *

Weeks of gestation at delivery *

Vaginal Birth or C-Section *

Vaginal Birth
C-Section

Any complications? *

Was this a surrogate pregnancy? *

Add a pregnancy #3

Add a pregnancy

Name of Child *

Sex *

Male
Female

Birthdate *//

Birthweight *

Weeks of gestation at delivery *

Vaginal Birth or C-Section *

Vaginal Birth
C-Section

Any complications? *

Was this a surrogate pregnancy? *

Add a pregnancy #4

Add a pregnancy

Name of Child *

Sex *

Male
Female

Birthdate *//

Birthweight *

Weeks of gestation at delivery *

Vaginal Birth or C-Section *

Vaginal Birth
C-Section

Any complications? *

Was this a surrogate pregnancy? *

Add a pregnancy #5

Add a pregnancy

Name of Child *

Sex *

Male
Female

Birthdate *//

Birthweight *

Weeks of gestation at delivery *

Vaginal Birth or C-Section *

Vaginal Birth
C-Section

Any complications? *

Was this a surrogate pregnancy? *

Have you ever experienced any complications of pregnancy: *

Pre-Eclampsia
Eclampsia
High Blood Pressure
Pre-Term Labor
Bleeding During Pregnancy
Gestational Diabetes
Postpartum Hemmorhage
Placental Issues
Intrauterine Growth Restriction
None

Would you terminate for Down’s syndrome or other chromosomal problems at your IPs’ request? (copy) *

If it was determined that the child would have severe physical or mental abnormalities (i.e. Genetic disorder, heart defect, short life expectancy) would you be willing to terminate? *

If the parents want a chorionic villus sampling (CVS) or amniocentesis done, would you be willing to? *

Would you be willing to pump, freeze, and ship your breast milk if your IP requested? *

Do you and your partner understand there will be times during the IVF process where you may be required to abstain from sexual activity while attempting to achieve a pregnancy for prospective parents? *

Do you want any additional children of your own? (IF ANSWER IS YES, SURROGACY COULD POSSIBLY AFFECT YOUR FERTILITY IN THE FUTURE) *

Are you willing to carry twins? *

Are you willing to carry embryos splitting to twins? *

Are you willing to reduce a twin pregnancy to singleton? *

Is there anything in particular you wouldn’t be ok with during your surrogacy journey? *

At the birth of the baby, are you comfortable with the IP(s) being in the delivery room? *

Are you willing to transfer untested embryos? (Embryos that have not undergone Pre-Implantation Genetic Screening- PGS, embryos that have not been genetically tested. In the past before technology advanced, PGS had not been done on the embryos and there were plenty of successful cases.) *

Are you willing to work with Intended Parents that may be HIV positive? *

So long as the IPs do not have an active virus, and you are confirmed Hep B immune, would you agree to work with IPs that have Hep B or those who have been exposed to Hep B? *

So as the IPs do not have an active virus, and you are confirmed Hep B immune, would you agree to work with parents that have gotten vaccinated to Hep B and have antibodies positive? *

Information submission

Please send 10+ pictures of you, you and your family, you at your job, you doing your favorite hobbies, you in nature, etc. Thank you! *

Click or drag files to this area to upload. You can upload up to 10 files.

I hereby certify that all of the above information is correct and agree to submit this application. *

I accept
I do not accept

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