Surrogates Application (Step by Step)

Occupation or Source of Income *

Marital Status *

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

History of miscarriage(s)? *

History of abortion(s)? *

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

Anemia? *

Severe vomiting lasting more than 3 months? *

Pre-eclampsia (swelling of feet, hands, or face)? *

Gestational diabetes? *

Hypertension during pregnancy? *

Blood transfusion during pregnancy? *

Seizures? *

Do you have regular menstrual cycles? *

Are you currently using birth control? *

Are you currently taking any medications? *

COVID-19 vaccinated? *

Hepatitis B vaccinated? *

Varicella (Chickenpox) vaccinated? *

Are you currently receiving any ongoing medical treatment? *

Any surgeries in the past 2 years? *

Anxiety or depression? *

Bipolar disorder, schizophrenia, or personality disorder? *

ADHD? *

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

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? *

Syphilis *

Hepatitis B or C *

Genital herpes *

HIV / AIDS *

Asthma? *

Heart conditions? *

History of cancer? *

Scoliosis? *

History of endometrial ablation? *

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? *

Any pending legal claims or lawsuits? *

Any past or present criminal record? *

Receiving any form of government assistance? *

Medical Records Source (if applicable) *