What is your residency status in US?

I am a US citizen

I am a permanent resident of the US

Other

Which city do you live in?

What is your race?

Highest level education you have completed

What is your job?

What is your marital status?

Are you currently breastfeeding?

Yes

What is your height?

What is your weight (lb.)?

Date of birth

How many babies have you delivered?

Please describe your 1st delivery experience.

Please describe your 2nd delivery experience. (If yes)

Please describe your 3rd delivery experience. (If yes)

Please describe your 4th delivery experience. (If yes)

Please describe your 5th delivery experience. (If yes)

Why do you want to be a surrogate?

Have you ever been a surrogate before?

Yes

Please describe your 1st surrogate delivery experience. (If yes)

Please describe your 2nd surrogate delivery experience. (If yes)

Please describe your 3rd surrogate delivery experience. (If yes)

Are you or your spouse currently on active or reserve duty in the military?

Yes

Have you been involved in a legal matter in the last year? Specifically, divorce proceedings, lawsuits, misdemeanors, custody disputes, and/or criminal offenses.

Yes

Do you and your partner understand that unless you have had a tubal ligation or your partner has had a vasectomy, you must agree to abstain from sexual activity while undergoing medical treatment and participating in this program? Any period(s) of abstinence will be directed by the physician.

Yes

Would you and your spouse able to sign the surrogate contract together if needed?

Yes

Do you have regular period?

Yes

Are you using birth control method?

Are you currently taking prescription medications for any of the following conditions? Select all that apply.

Have you ever used marijuana or herbal supplements?

Yes

Have you regularly smoked, vaped or used e-cigarettes in the last year?

Yes

Do you or your family or your sexual partners have a history of any of the following health conditions? Select all that apply.

What is most important to you when picking the intended parents to receive the baby?

Please select any or all you are willing to work with:

Heterosexual Couple

Same Sex Couple

Single Person

If there is a medical problem with pregnancy or with the child you are carrying as a surrogate and the intended parents want to consider termination, would you support them in making that difficult decision, based on the advice of their physician and personal beliefs?

Yes

Are you willing to carry twins or triplets?

Yes

Do you have a recruiter? If yes, please fill out the information below:

Recruiter Full Name
Recruiter Phone
Recruiter Email

First Name

Last Name

Phone *

Email *

State

By submitting this form, I agree to receive SMS communications and marketing messages at the phone number provided above from LifeBridge Surrogacy via the phone number (408) 412-7845. I understand that in addition to responses to any queries I send to LifeBridge Surrogacy, I may receive up to one marketing message per week. Data rates may apply. Reply STOP at any time to opt-out of all SMS messages from LifeBridge Surrogacy.