Surrogacy Program

Surrogate Application

Note: If you've already registered, use the 'Surrogate Login' link, above right.

See If You Qualify

Have you delivered a healthy child? If so, you can apply to become a surrogate and experience the opportunity of a lifetime, making dreams come true for you and an infertile family.

Please start by answering the following questions. We can tell you momentarily whether you may be a good candidate for surrogacy.

Please Note: Field names in this color are required.

First Name:
Last Name:
E-mail Address:
Home Phone:
Work Phone:
Cell Phone:
Best Number to Be Reached At:
Are you a U.S. Citizen?:
Yes     No    
What state do you live in?:
Zip:
Date of Birth:
Month: Day: Year:
     
What is your height?:
Weight:

Do you receive any of the following?
  AFDC
  Cash Aid
  Food Stamps
  Housing Aide
  Other

Please check all that apply.

If 'Other' is selected above, what type of government assistance?

Do you smoke or use tobacco in any form?
Yes     No    

Have you ever given birth before?
Yes     No    

Have you ever had gastric bypass surgery?
Yes     No    

How did you hear about our program?
Facebook
Internet-All About Surrogacy
Internet-Craig's List
Internet-Google Search
Internet-My Space
Internet-Other
Internet-SMO
Internet-Yahoo Search
Referral
Returning Surrogate

If you selected 'Referral' above, please tell us the name of the person who referred you.

Do you take any medications? If so, what kind and for what conditions?

Tell us about any past or current medical problems:

How many sexual partners have you had in the last year?
Zero
One
Two
Three
Four or More

How many c sections have you had?
Zero
One
Two
Three
Four or More

What is your level of interest in becoming a surrogate?
I am certain I would like to become a surrogate.
I am fairly certain I would like to become a surrogate.
I am gathering information from different agencies.
I have just heard about surrogacy and it sounds interesting.

Do you have your high school diploma or GED?
Yes     No    

Have you or your partner ever been convicted of a felony?
Yes     No    

Have you ever attempted suicide?
Yes     No    

Have you ever been diagnosed with high blood pressure?
Yes     No    

Have you ever been diagnosed with Diabetes (not gestational)?
Yes     No    

Have you ever been diagnosed with an incompetent cervix?
Yes     No    

Have you ever been diagnosed with Syphilis?
Yes     No    

Have you delivered 6 or more pregnancies?
Yes     No    

Do you have any history of Placenta Previa?
Yes     No    

Have you ever been diagnosed with a Toxemia?
Yes     No    

Have you ever been diagnosed with a Pre-Eclampsia?
Yes     No    

Do you have any history of Pregnancy-Induced Hypertension?
Yes     No    

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