Surrogate Application One of the most personally rewarding decisions you can make is to become a surrogate. After all, there are few things more valuable than making another person’s dream of having a child come true. While our application to become a surrogate may take some time to complete, please understand that the information you provide is extremely important to ensure that you are matched with like-minded intended parents to ensure your journey is as positive as can be. How did you hear about us? Who is your referral source? Experienced Surrogate Yes No, first time 1. About Yourself Legal Full Name * First Name Last Name Date of Birth * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Best Phone Number to reach you * Country (###) ### #### Second Best Phone number * Country (###) ### #### Email * Blood Type: * Height: * Weight: * Your Ethnicity/ Origin: * Hispanic and Latino Americans Asian Caucasian Alaska Natives or American Indian African Americans Native Hawaiian or Other Pacific Islander East Indian Middle Eastern or Arabic Multi - Ethnic Education Level: * Bachelor Master Posgraduate High school diploma or GED Marital status: * We MUST know your legal status; it can affect the Legal contract and your ability to be a surrogate. Legally Married Separated - still Legally Married In a Relationship Single Religion: Agnostic, Atheist, Declined to State Buddhist Christian Hindu, Sikh Jewish Muslim Other Are you currently employed: * Yes No How many hours do you work weekly? If you are employed* * 2. Basic / General Qualifications Are you a citizen or permanent resident of the United States? Yes No Are you between the ages of 21-44? Yes No Do you have a valid driver's license or resident ID? Yes No Are you in a stable living situation? at least 3 years of address verification Yes No Have you had at least 1 delivery, but no more than 5 and no more than 3 prior c-section deliveries? Yes No Do you have any medical problems? If so, please explain in detail 3. Medical / Pregnancy History Have you ever had any surgeries? If so please provide details for each surgery Number of pregnancies (please include miscarriages and abortions) * Number of children * Please list the age(s) of your child(ren) Have you delivered a child vaginally Yes No Have you had a cesarean (c-section)* Yes No Please provide details on the cesarean, if your answer was Yes: * List your 1st Pregnancy History * Year, Outcome, Baby's Weight at birth, Singleton List your 2nd Pregnancy History * Year, Outcome, Baby's Weight at birth, Singleton Please specify if you have had any of the following complications throughout any of your past pregnancies: Placenta Previa Yes No Toxemia Yes No Pre-Eclampsia Yes No Anemia * Yes No Pregnancy-induced hypertension Yes No Gestational Diabetes Yes No Was any of the previous pregnancy considered as high-risk? Yes No Do you smoke or use tobacco Yes No Have you used any illegal drugs in the past 18 months * Yes No Have you ever been a member of a drug or alcohol treatment program* * Yes No Have you ever used a mind altering drug such as marijuana, cocaine, heroin, ecstasy, LSD or methamphetamines? If so, please explain which drug, frequency of use, and last date used Are you currently taking any medications? If yes, please list each medication and the reason the medication has been prescribed to you* * Number of sexual partners in the past 12 months* Number of sexual partners in the past 30 days* Have you or your partner tested positive for Chlamydia in the past 12 months? * Yes No Have you or your partner tested positive for Gonorrhea in the past 12 months? * Yes No Have you or your partner tested positive for Syphilis in the past 12 months? * Yes No Have you or your partner tested positive for Chlamydia in the past 12 months? * Yes No Have you or your partner tested positive for HIV/AIDS?* * Yes No Have you ever been diagnosed with Genital Herpes? * Yes No Have you received a tattoo in the past 12 months? * Yes No Have you received a piercing in the past 12 months? * Yes No Do you currently have health insurance? * Yes No When was your last pap smear and what was the result (if abnormal what was your doctors suggested course of action?)* * 4. Personal History Have you ever been arrested? * Yes No Have you ever received a DUI or DWI? * Yes No Have you or your partner ever been convicted of a felony? * Yes No Have you ever been diagnosed as clinically depressed? * Yes No Have you ever been diagnosed with post-partum depression? * Yes No Have you ever been prescribed anti-depressants? * Yes No Have you ever been prescribed anti-anxiety medication? * Yes No Have you ever attempted suicide? * Yes No Have you ever had a child removed from your home? * Yes No Have you ever lost custody of a child? * Yes No Have you ever been a victim of domestic violence? * Yes No If your application is approved are you (and your spouse if applicable) willing to have a full background check conducted and released to Gifted Conceptions? * Yes No Completing the application by providing all and correct information takes time and effort, if you need additional help, simply reach out to us today, we will assist with requesting previous medical records, review the questions to make sure the information are most up to date and accurate. Thank you! We will call for the next steps.
