Apply to Be a Surrogate

Surrogate Intake Application

PERSONAL INFORMATION
First Name
Last Name
Address
City
State
Zip
Home Phone
Cell Phone
Work Phone
eMail
Alternate eMail
Date of Birth
Age
Height
Weight	pounds
BMI

Do you smoke?	Yes No
If yes, how many cigarettes per day?
If yes, are you willing to quit now?	Yes No

When was your last physical or pap smear?
Current contraceptive method
Do you have regular menstural cycles?	Yes No

SOCIAL INFORMATION
Do you have a criminal record, inclduing DUI / DWI?	Yes No
If yes, please list charges, date of offense and outcome
Marital Status	Single Married Signficant Other Divorced Separated
Name of Spouse or Significant Other:
Spouse or Significant Other's Phone Number
Is your spouse or significant other supportive of you being a surrogate?	Yes No

Highest Level of Education
Are you receiving any welfare payments or public assistance from any city, state, or federal agency?	Yes No
If yes, do you or your spouse work?	Yes No
Other sources of income?
Have you ever been diagnosed with or treated for depression or any mental disorder?	Yes No
If yes, at what age?
How long were you under the care of a physician?
What drugs were used for treatment?

The clinic may not be in your local area. You may be required to travel and be gone for 3 - 4 days. Are you willing and able to take time off from work and be away from home for that amount of time?	Yes No
Do you have a Valid Passport?	Yes No
If yes, Expiration Date

SURROGACY INFORMATION
Are you applying to be a:	Gestational Carrier Traditional Surrogate
Have you considered self-matching?	Yes No
What specifications do you have about the types of parents you'll work with, selective reduction, etc. ?
Have you contacted or signed an agreement with any other agencies?	Yes No
Are you listed on any surrogacy web sites?	Yes No
Are you willing to sign an exclusive agreement with our agency?	Yes No
Have you applied to be a surrogate before?	Yes No
If yes, were you accepted?	Yes No
If yes, when?
If yes, where?
If yes, how many times?
If yes, why are you no longer working that agency?
Are you seeking a fee?	Yes No
If yes, how much?

PREVIOUS PREGNANCIES
	1st	2nd	3rd	4th	5th
Months to conceive?
Miscarriage or abortion?	Yes No	Yes No	Yes No	Yes No	Yes No
Gender	Male Female	Male Female	Male Female	Male Female	Male Female
Date of Birth
Full term?	Yes No	Yes No	Yes No	Yes No	Yes No
Birth weight?
Problems or Complications?	Yes No	Yes No	Yes No	Yes No	Yes No
Caesarean or Vaginal?	Caesarean Vaginal	Caesarean Vaginal	Caesarean Vaginal	Caesarean Vaginal	Caesarean Vaginal
Physical or Mental Birth defects?	Yes No	Yes No	Yes No	Yes No	Yes No

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