Surrogate Application "*" indicates required fields BASIC INFORMATIONName* First Last Phone*Email* Referred by Age* Address*Height* Weight* BMI* Ethnicity* Have you been a surrogate before? Yes No Occupation* Number of Biological Children*Please enter a number from 0 to 50.Marital Status*SingleMarriedEngagedLive-In BoyfriendCommitted PartnerDo you smoke?* Yes No Do you drink alcoholic beverages?* Yes No Are you willing to carry twins?* Yes No Are you Hepatitis B immune?* Yes No I would like to request you to provide personal photos that sense of more warmth, sunshine, and loveliness. These photos may include individuals and with families.Upload your Best Profile Photo*Accepted file types: jpeg, jpg, png, pdf, Max. file size: 50 MB.Best Solo Head ShotUpload Photos* Drop files here or Select files Accepted file types: jpeg, jpg, png, pdf, Max. file size: 50 MB, Max. files: 10. Upload Your Intro VideoMax. file size: 50 MB. PRIOR PREGNANCIES: Pregnancy #1Child’s Name Child’s date of birth MM slash DD slash YYYY C-section or Vaginal C-Section Vaginal Weeks at conclusion of pregnancy Gender Male Female Birth Weight Any complications? Yes No Did you have any trouble getting pregnant? Yes No PRIOR PREGNANCIES: Pregnancy #2Child’s Name Child’s date of birth MM slash DD slash YYYY C-section or Vaginal C-Section Vaginal Weeks at conclusion of pregnancy Gender Male Female Birth Weight Any complications? Yes No Did you have any trouble getting pregnant? Yes No PRIOR PREGNANCIES: Pregnancy #3Child’s Name Child’s date of birth MM slash DD slash YYYY C-section or Vaginal C-Section Vaginal Weeks at conclusion of pregnancy Gender Male Female Birth Weight Any complications? Yes No Did you have any trouble getting pregnant? Yes No PRIOR PREGNANCIES: Pregnancy #4Child’s Name Child’s date of birth MM slash DD slash YYYY C-section or Vaginal C-Section Vaginal Weeks at conclusion of pregnancy Gender Male Female Birth Weight Any complications? Yes No Did you have any trouble getting pregnant? Yes No MEDICAL HISTORYDo you have any current or past health concerns (describe):List any medications (prescription and non-prescription), vitamins and nutritional supplements you are currently taking and dosage:List all prescription medications and dosages you have taken in the last year and your reason for taking them:How often do you go to the doctor? How many days did your most recent period last: Describe your current method of birth control:Have you ever been hospitalized other than giving birth (describe):When was your last pap smear?What were your pap smear results:When were your last screening for STDs?What was your last STDs screening results?Have you ever been in therapy or counseling? (describe reason):Do you have any allergies (describe): ABOUT YOUR SURROGACYIf bed rest is prescribed during pregnancy, will you require childcare assistance? Yes No Notes:Two embryo transfers are standard to give the parents the best chance at a single pregnancy. Are you willing to have two embryos transferred? Yes No Notes:Are you willing to allow the doctor to decide the best number of embryos to transfer to achieve a single pregnancy (no more than three)? Yes No Notes:Would you be willing to terminate pregnancy if medically advised? Yes No Notes:If the fetus were diagnosed with Down syndrome (Trisomy 21), would you be willing to terminate the pregnancy? Yes No Notes:If you were to become pregnant with more than triplets (3), would you be willing to reduce the number of embryos within the firsttrimester if requested by the Intended Parents? Yes No Notes: ABOUT YOURSELFHow did you become interested in becoming a gestational surrogate?Who is the primary source of income in your home?What is your educational background?Have you ever been convicted of a crime?What does being a surrogate mother mean to you?What relationship do you want with the intended parents during the pregnancy?Would you be willing to work with a same sexed couple or single parent?Many intended parents do not live near their surrogate and may live in another country. How do you feel about having intended parents that do not live near you?Describe your daily diet:Do you currently exercise or workout? Please describe your current exercise routine:What activities do you enjoy for fun and recreation:Describe the home you live in:CAPTCHA