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Surrogates Application

Congratulations – You Qualify!

We're thrilled to let you know that based on your answers, you meet the basic requirements to become a surrogate with Yunda Surrogacy. That's a beautiful first step toward helping someone build their family — and we're so honored to walk this journey with you.

The next step is to complete a more detailed questionnaire about your background, health history, and preferences. This helps us understand you better and ensures that we can match you with intended parents who are the right fit — emotionally, ethically, and practically.

Thank you for considering this incredible act of generosity.

I. General Information

Format: MM/DD/YYYY

ftin
lbs

Automatically calculated based on height and weight

Occupation or Source of Income *

Marital Status *

Are you a U.S. Citizen or Legal U.S. Resident? *

Ethnicity (Select all that apply)*

II. Pregnancy & Birth History

History of miscarriage(s)? *

History of abortion(s)? *

III. Delivery History

Have you been a surrogate before? If yes, when? *

IV. Pregnancy-Related Medical History

Do you have a history of any of the following?

Anemia? *

Severe vomiting lasting more than 3 months? *

Pre-eclampsia (swelling of feet, hands, or face)? * Note: OB Care Letter required

Gestational diabetes? *

Hypertension during pregnancy? *

Blood transfusion during pregnancy? *

Seizures? *

V. Medical & Health History

Do you have regular menstrual cycles? *

Are you currently using birth control? *

Are you currently taking any medications? *

If more than 2 years ago, an updated Pap smear will be required

Gestational Carriers must be willing to receive required vaccinations as medically indicated

COVID-19 vaccinated? *

Hepatitis B vaccinated? *

Varicella (Chickenpox) vaccinated? *

Are you currently receiving any ongoing medical treatment? *

Any surgeries in the past 2 years? *

VI. Mental Health History

Have you ever been diagnosed with or treated for any of the following?

Anxiety or depression? *

Bipolar disorder, schizophrenia, or personality disorder? *

ADHD? *

Are you currently taking any medication for anxiety or depression? *

VII. Substance Use History

Any drug use during previous pregnancy/pregnancies? *

Do you currently smoke marijuana? *

Did you smoke or vape during previous pregnancy/pregnancies? *

Do you drink alcohol? *

VIII. Infectious Disease History

Any past or present diagnosis of

Syphilis *

Hepatitis B or C *

Genital herpes *

HIV / AIDS *

IX. Other Medical Conditions

Asthma? *

Heart conditions? *

History of cancer? *

Scoliosis? *

History of endometrial ablation? *

X. Preferences & Matching Considerations

Open to carrying twins? *

Open to fetal reduction if medically recommended? *

Open to termination if medically indicated? *

Open to amniocentesis / CVS testing? *

Open to working with same-sex or single Intended Parents? *

Willing to pump breast milk after delivery? *

Open to Intended Parents with HIV? *

Open to Intended Parents with Hepatitis B? *

XI. Legal & Administrative

Any pending legal claims or lawsuits? *

Any past or present criminal record? *

Receiving any form of government assistance? *

XII. Notes / Internal Use

Medical Records Source (if applicable) *

Upload Photos *

+Click or drag images here to upload (minimum 2)

Final Consent

Your information will be kept strictly confidential and will not be shared or sold to any third parties.