Become a Surrogate Application - Start The Surrogacy Processs

1Basic Information

2Characteristics and Lifestyle

3Medical and Reproductive History

4About Your Surrogacy Journey

5Letter to Intended Parents

6Pregnancy History

7Photos

Name *

Email *

Phone

Age *

What is your Height/weight *

Number of previous pregnancies

Any complications? *

If yes, explain

Do you smoke, drink or use illegal drugs? *

Have you been convicted of a crime? *

Do you have a pending divorce?

Race

Primary Language

Education

Career/Job

Religion

Are you a US citizen or legal resident? *

Do you have a spouse or partner? *

Does he/she support your decision to become a surrogate mother/gestational carrier?

Does he/she understand that they will need to:

Please describe your support system if you were to become a gestational carrier.

Do you have personal health insurance? *

If yes, what type?

Name of Health Insurance Provider:

Does it have coverage benefits for maternity services? *

In the last 12 months, have you smoked, vaped, used nicotine patches or an e-cigarette? *

In the last 12 months, has your partner/spouse smoked, vaped, used nicotine patches or an ecigarette? *

Do you live or work in a smoking environment? *

Do you drink? *

How often?

In the last 12 months, have you used any illegal drugs including marijuana? *

If yes, what was it and when?

In the last 12 months, has your partner/spouse used any illegal drugs including marijuana? *

If yes, what was it and when?

Have you ever been arrested? *

Please explain and provide dates:

Has your spouse/partner ever been arrested? *

Please explain and provide dates:

Practicing Religion

Do you drive and have your own vehicle? *

If no, please describe your transportation for required appointments

Is your schedule flexible to attend several required appointments? *

If no, please explain your scheduling restrictions

In the last 6 months, have you traveled outside of the country? *

If yes, where and when? (copy)

In the last 6 months, has your spouse/partner traveled outside of the country? *

If yes, where and when?

Did you graduate high school? *

Did you graduate college? *

If yes, what was your major?

Other Certifications

Describe your general health *

Do you know if you have or are a carrier of sickle cell anemia? *

Have you had any surgeries or hospitalizations that were not pregnancy-related? *

If yes, please explain

Blood Type *

Are you Rh negative? *

Have you been diagnosed with any of the following? (check all that apply)

First Choice
Second Choice
Third Choice

Have you ever been treated for depression and/or anxiety? *

If yes, please list when and what type of treatment you had:

Did you experience postpartum depression after any of your pregnancies? *

If yes, please explain:

Have you ever been medicated or hospitalized for psychiatric reasons? *

If yes, please explain:

Please list all medications you are currently taking including OTC (over-thecounter) medications and vitamins/supplements

Are you allergic to latex? *

Please list any other known allergies

Do you have a menstrual cycle every month? *

When was the first day of your last period?

Approximately how many days between the first day of each period?

Have you had a PAP smear completed in the last 12 months? *

When did you have your last PAP smear? Please provide the exact date if possible.

Name of facility where the PAP was performed:

Results?

Are you currently using any type of birth control or contraceptives? *

If yes, what kind?

If you have an IUD or use an injection or implant, are you willing to discontinue using them to be approved as a gestational carrier? *

Are you currently breastfeeding? *

If yes, how often?

When are you planning to stop?

How many biological children have you given birth to? *

How many children do you have in your custody that were not birthed by you? *

Are any of your children adopted? *

Do you have legal custody of all of your children? *

If no, please explain:

Current OB/Gyn

City

State

Is this the Ob/Gyn you will use for your surrogacy prenatal care? *

Why are you interested in becoming a surrogate mother/gestational carrier? *

Which of the following types of Intended Parent(s), are you be willing to be matched with?

First Choice
Second Choice
Third Choice

What characteristics are you looking for in potential Intended Parents? *

What contact do you want, before, during and after the pregnancy? *

How many embryos are you willing to have transferred at once? *

Are you willing to carry multiples if a single embryo splits? *

Selective reduction, or multifetal pregnancy reduction is only considered if you are pregnant with triplets (or more). It is a procedure to reduce the number of fetuses in the uterus. According to the American Society of Reproductive Medicine (ASRM), the risk of miscarriage (spontaneous abortion) and other problems increases with the number of fetuses present, this procedure may be performed in an attempt to prevent the entire pregnancy from aborting or delivering very prematurely. *

Would you agree to defer the decision of selective reduction to your Intended Parents in the event of a triplet pregnancy? (check all that apply)

First Choice
Second Choice
Third Choice

The vast majority of our Intended Parents have their embryos genetically screened prior to implantation. This allows the parents to be better aware of any potential physical or mental abnormalities their baby may be diagnosed with during the pregnancy. Would you agree to defer the decision of termination to your Intended Parents? (check all that apply)

First Choice
Second Choice
Third Choice

Will you be able to locate assistance to help with your children, if, for any medical reason, you are told to be on bed rest? *

What concerns do you have about bonding with the baby during the pregnancy knowing the baby belongs to the I t d d P t( )?

Name of Delivery Hospital

Name of OB/Gyn seen during this pregnancy

Have you ever been a surrogate/gestational carrier before? *

What year(s) did you deliver?

Were you Traditional or Gestational Surrogate?

What method(s) was/were used for the pregnancies?

Did you work with a fertility clinic(s)? *

If yes, which one(s)?

Did you work with an agency(ies)? *

If yes, which one(s)?

How was your experience with this agency(ies)?

What type of pregnancy was/were your surrogacy(ies)?

How many embryo transfer attempts were completed?

Were any of your cycles cancelled? *

If yes, please explain:

Did you experience any complications from the fertility medications? *

If yes, please explain:

Did you undergo selective reduction or termination? *

If yes, please explain:

How did you feel after the delivery(ies)? (Any depression, separation anxiety with the baby)

Based on your previous experience, what adjustments would you want for your next journey?

Please write a letter to your potential Intended Parents sharing more about who you are and what it will mean for you to be their surrogate: *

This is where you recird detaild about any past pregnancies.
Add a new delivery by clicking Add.
If you had multiple birth (i.e. twins) you must complete record for each in the set (i.e two for twins, three for triples)
Select Yes in the Surrogate dropdown if you were a surrogate for that delivery.
Enter the number of menstrual or IVF cycles completed leading to conception under Cycles to Concieve. This field is not required if you if you select No from the surrogate dropdown.
Details you enter in Complications are not displayed on your Maching Profile

Pregnancy Type

Gender of baby at Birth

Was this a surrogate delivery

Multiple Birth

Delivery Type

Weight of baby

Weeks at Delivery

Date of Birth

Complications

Photos Upload

Click or drag files to this area to upload. You can upload up to 10 files.

(only extension .jpg and .png)

Apply to Become a Surrogate