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Who referred you to us? *
Name *
Primary Race *
City/State/Zip Code *
Country United States of America Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia (Plurinational State of) Bonaire, Saint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo (Democratic Republic of the) Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Côte d'Ivoire Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini (Kingdom of) Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland (Republic of) Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea (Democratic People's Republic of) Korea (Republic of) Kosovo Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia (Federated States of) Moldova (Republic of) Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Macedonia (Republic of) Northern Mariana Islands Norway Oman Pakistan Palau Palestine (State of) Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russian Federation Rwanda Réunion Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Sweden Switzerland Syrian Arab Republic Taiwan, Republic of China Tajikistan Tanzania (United Republic of) Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkmenistan Turks and Caicos Islands Tuvalu Türkiye Uganda Ukraine United Arab Emirates United Kingdom of Great Britain and Northern Ireland United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State Venezuela (Bolivarian Republic of) Vietnam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands
Height/Weight/BMI *
Occupation *
Current Relationship Status *
How many years have you been together? *
Name of partner/spouse (First, Middle, Last) *
Level of education *
Do you have any religious or spiritual preferences? *
Are you able to attend all local appointments? * Yes No
What is your main source of income? *
How soon would you like to begin your Surrogacy journey? * Right Away 6 Months A Year
Have you ever applied to any other agencies as a surrogate or egg donor? * Yes No
Are there any other people residing in your home other than your children? * Yes No
If yes please list children in home.
Are you able to travel out of state for 2-3 days if travel expenses including childcare and lost wages are reimbursed? * Yes No
Do you have an existing health insurance policy? * Yes No
If yes, who is your insurance provider?
Have you ever been arrested? * Yes No
Do you drink alcoholic beverages? If so, how often – i.e. only on social occasions? * Yes No
How often? *
Have you or your partner ever been investigated by governmental child protective agency? * Yes No
Please explain investigation.
Do you or your partner currently have any legal cases or claims pending? * Yes No
Please explain legal cases or claims pending.
Have you or your partner ever been involved in any lawsuit? * Yes No
Please explain the lawsuit.
Have you ever used illicit drugs (marijuana, cocaine, methamphetamines?) (Please note that you will be tested.) * Yes No
Please explain the drug use (last time used, etc.)
Are you exposed to any second-hand smoke at home or at work? * Yes No
If yes, please explain the second-hand smoke.
Have you or your partner ever been arrested? * Yes No
If yes please explain (including DUI arrests) and provide date.
Have you ever been a surrogate or egg donor before? * Yes No
If yes, how many times, dates?
Under what circumstances would you termination of pregnancy? (I.E. medical consider advisement, selective reduction, severe abnormalities?) *
How many babies are you willing to carry during this surrogacy journey? * Only one Twins
How many biological children do you have? *
Are all of your children living with you currently? * Yes No
Do you have legal custody of your children? * Yes No
Do you plan on having more children of your own? * Yes No
What is your current birth control method? *
Do you have a regular menstrual cycle? * Yes No
Do you have any past or current medical issues? * Yes No
Are you allergic to any medication? * Yes No
Have you ever been prescribed any medications in the last 5 years? * Yes No
If yes please explain medications.
Have you had any surgeries? * Yes No
If yes, please list all reasons for surgery and month/year of surgery.
TB/exposed to TB? * Yes No
Explain TB
Explain Hepatitis B
Explain Hepatitis C
Cancer? * Yes No
Explain cancer
Irregular Heartbeat? * Yes No
Explain Irregular Heartbeat
Heart problems / congenital heart defect? * Yes No
Explain Heart problems / congenital heart defect
Head injuries? * Yes No
Explain Head injuries
Thyroid Problems? * Yes No
Explain Thyroid Problems
Seizures? * Yes No
Explain Seizures
Anemia? * Yes No
Explain Anemia
Genital Warts? * Yes No
Explain Genital Warts
Chlamydia? * Yes No
Explain Chlamydia
Gonorrhea? * Yes No
Explain Gonorrhea
Genital Herpes? * Yes No
Explain Genital Herpes
Syphilis? * Yes No
Explain Syphilis
HIV? * Yes No
Explain HIV
Hepatitis B? * Yes No
Explain Hepatitis B
Hepatitis C? * Yes No
Explain Hepatitis C
Ovarian Cysts? * Yes No
Explain Ovarian Cysts
HPV? * Yes No
Explain HPV
Have you ever had any miscarriages? This excludes any chemical pregnancies (where the heartbeat was never detected.) * Yes No
Explain Miscarriages
Have you had any abortions? * Yes No
Explain Abortions
Was this pregnancy for yourself or a surrogacy journey?
Date of delivery
Weeks of gestation
Any complications? * Yes No
Explain complications
Number of babies delivered?
Vaginal or C-section?
Explain C-section
Childs Birth Weight
Was this pregnancy for yourself or a surrogacy journey?
Date of delivery
Weeks of gestation
Any complications? * Yes No
Explain complications
Number of babies delivered?
Vaginal or C-section?
Explain C-section
Child's Birth Weight
Have you or your partner if applicable ever had psychological counseling? * Yes No
Explain counseling
Have you ever been prescribed any psychiatric medications (including anti-depressants and anti-anxiety medications?) * Yes No
Explain medications
Have you ever been diagnosed with any of the following? drug or alcohol addiction, an eating disorder, schizophrenia, depression, nervous breakdown, bi-polar disorder, personality disorder, anxiety? * Yes No
Explain diagnosis
Have you ever been hospitalized for psychiatric care? * Yes No
Explain psychiatric care
Have you ever attempted suicide? * Yes No
Explain attempt
Base fee?
Why do you want to become a surrogate?
What would you like the Intended Parents know about you?
What kind of relationship would you like with your IP's during your surrogacy journey? (friendship, very little to NO communication)
What kind of relationship would you like after delivery?
Would you be comfortable with the IP's in the delivery room?
Would you be willing to pump after delivery?
Are you comfortable having the IP in the transfer room/or recording the transfer for the IP?
Name at least 3 people who your support system consist of?
Are you comfortable with injections and taking oral medication for surrogacy?
Describe your personality.
What does your daily routine consist of?
What do you do for fun?
What are your hobbies?
What is your favorite way to spend time with your family?
What is your favorite color?
What is your favorite dessert, candy or snack food?
What is your favorite Movie or TV show?
What is your favorite way to relax?
Favorite type of jewelry (I.E. rings, necklaces, or bracelets?)
