First Name
*
Last Name
*
Email
*
Primary Phone Number
*
Preferred method of contact
*
Please select from the drop down:
Email
Text Message
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What is your nearest major city?
*
Home Address
*
City
*
State
*
Postal Code
*
Date of birth
*
Are you a U.S. Citizen?
*
Yes
No
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Why do you want to become a surrogate?
*
Have you applied as a surrogate with any other agencies?
*
Please select from the following:
Yes
No
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For the following questions, please rank what is most important to you on a scale of 1 to 5.
On this scale, 1 is the most important factor, and 5 is the least important.
Location of Agency
*
How important is the agency location (from 1 to 5)?
1 - Extremely Important
2 - Important
3 - Neutral
4 - Slightly Important
5 - Not at all important
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Compensation
*
How important is your compensation (from 1 to 5)?
1 - Extremely Important
2 - Important
3 - Neutral
4 - Slightly Important
5 - Not at all important
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Time to match with intended parents
*
How important is time to match with intended parents (from 1 to 5)?
1 - Extremely Important
2 - Important
3 - Neutral
4 - Slightly Important
5 - Not at all important
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Location of intended parents and/or fertility clinic
*
How important is the location of the intended parents and/or fertility clinic (from 1 to 5)?
1 - Extremely Important
2 - Important
3 - Neutral
4 - Slightly Important
5 - Not at all important
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Support group with current/past surrogates
*
How important is access to a support group with current/past surrogates (from 1 to 5)?
1 - Extremely Important
2 - Important
3 - Neutral
4 - Slightly Important
5 - Not at all important
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What is your height?
*
What is your current weight?*
*
Are you trying to gain/lose weight?
*
Please select from the following:
I am trying to lose weight
I am trying to gain weight
I am not trying to lose or gain weight
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Do you smoke?
*
Please select from the following:
Yes
No
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Are you around secondhand smoke?
*
Please select from the following:
Yes
No
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Do you use cannabis products?
*
Please select from the following:
Yes
No
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Have you had any tattoos or piercings in the last 6 months?
*
Please select from the following:
Yes
No
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How many pregnancies have you had?
*
Do you have children?
*
Please select from the following:
Yes
No
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How many children do you have?
If so, what are their ages?
Did you have any pregnancy complications?
Are you currently breastfeeding? If yes, when do you plan to stop breastfeeding? If you are breastfeeding currently, are you having regular periods?
Have you ever been convicted of a crime?
*
Please select from the following:
Yes
No
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If yes, please explain.
Are you taking any medications?
*
Please select from the following:
Yes
No
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If yes, list medications, what they are prescribed for, and how long you have been taking them.
Are you receiving any of the following forms of government assistance? Check all that apply.
*
Food Stamps
Medicaid
Cash Assistance / Welfare
WIC
SSI
Public Housing / Section 8
Government Subsidized Childcare
Other (Please Specify)
None of the above
Do you or your partner/spouse have any past or current or ongoing cases with Child Protective Services?
*
Please select from the following:
Yes
No
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What is your readiness to begin the surrogacy process?
*
Please select from the following:
I am ready to get started right now
I am interested in getting started in approximately 6 months
I'm not sure. I am doing research and gathering information
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Would you be interested in speaking with an experienced surrogate mother about the surrogacy process and her surrogacy journey?*
Yes
No
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Nota: No podemos aceptar la forma con respuestas en Español. Debe enviar la forma en Inglés. Además, solo podemos aceptar solicitudes de ciudadanos de los Estados Unidos.
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