Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Date of Birth
MM
DD
YYYY
Are you an experienced surrogate?
*
No this is my first time
Yes I have been a surrogate before
What is your Blood Type
What is your Highest level of education
Number of years in your current relationship?
*
I am not in a relationship
I am in a new relationship less than 1 year
I have been in my relationship 1 -3 years
I have been in my relationship 3-5 years
I have been in my relationship 5+ years
What is your sexual orientation?
*
Straight
Gay
other
What is your occupation
What is your Spouse/Partner's occupation
First Pregnancy - Delivery Date
MM
DD
YYYY
What type of delivery?
*
Birth Weight
*
What was the sex of your baby?
What was the gestational period of the pregnancy?
Any issues with this pregnancy? If yes please explain.
Second Pregnancy - Delivery Date
MM
DD
YYYY
What type of delivery?
Birth Weight?
What was the sex of your baby?
What was the gestational period of the pregnancy?
Any issues with this pregnancy? If yes please explain.
Third Pregnancy - Delivery Date
MM
DD
YYYY
What type of delivery?
Birth Weight?
What was the sex of your baby?
What was the gestational period of the pregnancy?
Any issues with this pregnancy? If yes please explain.
Fourth Pregnancy - Delivery Date
MM
DD
YYYY
What type of delivery?
Birth Weight?
What was the sex of your baby?
What was the gestational period of the pregnancy?
Any issues with this pregnancy? If yes please explain.
Have you ever had an abortion, elective or otherwise?
If you have had an abortion what was the date of that procedure?
MM
DD
YYYY
If you have had a second abortion what was the date of that procedure?
MM
DD
YYYY
Have you ever had miscarriage?
If you have had a miscarriage, what was the date?
MM
DD
YYYY
If you have had a second miscarriage, what was the date?
MM
DD
YYYY
Delivering less than 36 weeks in any pregnancy?
Are you willing to carry twins?
What is the maximum number of embryos you are willing to have transferred?
Would you undergo a selective reduction procedure if a multiple pregnancy is confirmed?
Would you agree to undergo an amniocentesis or CVS?
If there is a medical problem with the pregnancy, or (for any physical or genetic abnormalities) with the child you are carrying as a surrogate and the Intended Parents want to consider abortion, would you allow them to make the decision based on the advice of their physician and personal beliefs?
What relationship do you want with the Intended Parents during conception and pregnancy?
Weekly checkups, pictures, video chat, it’s up to whatever the IPs agree to?
Are you willing to work with a gay couple or single parent?
Are they any Intended Parent types you are not comfortable with?
Would you like to meet the Recipient Couple?
Do you have any health issues or concerns?
Did you have any complications in pregnancy? For example: Pre-Eclampsia, Gestational Diabetes, Placenta Previa or IUGR? If Yes please explain.
Do you have any history of anxiety or depression? If so did you take any medication?
Are you currently taking any medications? Herbal Supplements?
Do you smoke or vape (marijuana or tobacco)?
Do you drink alcohol? If so how much and how often.
Do you or have you ever taken any illegal drugs?
What is your current method of birth control?
Are your period cycles regular? How many days?
Have you ever had an abnormal Pap Smear?
Do you have surrounding family, and do you have their support in this matter?
Please provide some detail for the Intended Parents, so they know you have a supporting and loving environment.
What qualities would you consider most import in choosing a Recipient Couple?
Please describe your personality and character.
What are your hobbies, interests and talents?
What do you like to do in your spare time?
What’s your life philosophy?
Why do you want to be a Surrogate?
What do you plan to tell your children about your being a Surrogate?
Do you and your partner understand that, unless you have had a tubal ligation or your partner has had a vasectomy, you must agree to abstain from sexual activity while undergoing hormonal treatment embryo transfer? THIS DOES NOT MEAN SEX FOR THE ENTIRE SURROGACY. During the term of your Surrogacy Contract any sexual activity with your Spouse/Partner must be with approval of your Treating Physician.
Is there anything you would like to share with the intended Parents about you?
