Surrogate Application Personal information Name (First, Middle, Last): Primary Race: Date of birth Address Street Address Street Address Line 2 City State Zip Code Contact information Email Phone Others Height Weight BMI Occupation Current Relationship Status How many years have you been together? Name of partner/spouse(First, Middle, Last) What is your level of education? Do you have any religious or spiritual views? Are you able to attend all local appointments? * Yes No Are you actively parenting at least one of your own children? Yes No What is your main source of income? How soon would you like to begin your Surrogacy journey? Right away 6 months 1 year Have you ever applied to any other agencies as a surrogate or egg donor? (if yes what agency?) * Yes No Are there any other people residing in your home other than your children? or your partner? Yes No 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? Background Do you drink alcoholic beverages? Yes No If so how often? Have you or your partner ever been investigated by governmental child protective agency? Yes No Do you or your partner currently have any legal cases or claims pending? Yes No If Yes, please explain Have you or your partner ever been involved in any lawsuit? Yes No If Yes, please explain Have you ever used illicit drugs (marijuana, cocaine, methamphetamines)? Yes No Are you exposed to any second-hand smoke at home or at work? Yes No Have you or your partner ever been arrested? (including DUI arrests) Yes No Medical/Reproductive History Have you ever been a surrogate or egg donor before? * Yes No Under what circumstances would you consider termination of pregnancy? (I.E. medical advisement, selective reduction, sever abnormalities?) How many babies are you willing to carry during this surrogacy journey? 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 Have you had any surgeries? Yes No Have you ever been diagnosed with : TB/exposed to TB Cancer Irregular Heartbeat Heart Problems/Congenital Heart defect Head Injuries Thyroid Problems Seizures Anemia Genital Warts Chlamydia Gonorrhea Genital Herpes Have you ever been diagnosed with Syphilis? HIV Hepatitis B Hepatitis C Ovarian Cysts HPV Have you ever had any miscarriages? This excludes any chemical pregnancies (where the heartbeat was never detected) Yes No Have you had any abortions? Yes No Have you been vaccinated for covid-19? Yes No Pregnancy #1 Was this pregnancy for yourself or a surrogacy journey? Myself Surrogacy journey Date of delivery Weeks of gestation Any complications? Yes No Number of babies delivered? Pregnancy #2 Was this pregnancy for yourself or a surrogacy journey? Myself Surrogacy journey Date of delivery Weeks of gestation Any complications? Yes No Number of babies delivered? Vaginal or C-section? Yes No Childs Birth Weight Psychological History Have you or your partner if applicable ever had psychological counseling? Yes No Have you ever been prescribed any psychiatric medications? (including anti-depressants and anti-anxiety medications) * Yes No 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 Have you ever been hospitalized for psychiatric care? Yes No Have you ever attempted suicide? Yes No Surrogacy Questions 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? Yes No Would you be willing to pump after delivery? Yes No Are you comfortable having the IP in the transfer room/or recording the transfer for the IP? Yes No Name at least 3 people who your support system consist of? Are you comfortable with injections and taking oral medication for surrogacy? Yes No About you 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 flower? What is your favorite color? What is your favorite way to relax? What is your favorite Movie or TV show? What is your favorite dessert, candy or snack food? Favorite type of jewelry? (I.E. rings, necklaces, or bracelets?) How did you hear about us? Can you send us a few pictures of you? I swear or affirm that the above and foregoing representations are true and correct to the best of my information, knowledge, and belief. Sign date 寄送
