SURROGATE APPLICATION

Personal Information

Name:*

Age*

Date of Birth*

Height:*

Weight:*

City and State:*

Ethnicity:*

Are you a permanent U.S. resident or citizen?*

Yes

No

Have you ever given birth? (not qualified for surrogacy if your answer is No, no need to continue)*

Yes

No

Number of Children:*

Vaginal Deliveries:*

C-Section Deliveries:*

Previous Surrogate?*

Yes

No

Insurance:*

Yes

No

If answer “Yes” to above, insurance company:

Termination of pregnancy if doctor or the Intended Parent requests:*

Yes

No

Have you used any form of tobacco or vape in the past 12 months?*

Yes

No

Have you used any form of marijuana in the past 12 months?*

Yes

No

Do you take any medications either over the counter or prescription?*

Yes

No

Are you actively parenting at least one of your children?*

Yes

No

Have you ever been convicted of a felony?*

Yes

No

In the past 12 months have you received a tattoo or piercing?*

Yes

No

Type of relationship:*

Single

Divorced

Married

Spouse/Partner Name (if applicable):

Do you have a car for all the appointments?*

Yes

No

Are you employed outside of the home?*

Yes

No

If answer “Yes” to above, your current occupation:

Is your spouse/partner employed?

Yes

No

N/A

If answer “Yes” to above, your spouse occupation:

Did you graduate from high school?*

Yes

No

Highest level of education*

How many sexual partners have you had in the past 12 months*

1/5

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