Surrogate Application

First Name *

Last Name *

Age *

Date of Birth *

Address *

City *

State Zip Code

How did you hear about us? *

Email address *

Home Phone Number *

OK to leave message? *

Cell Phone Number*

Best way to contact you.: *

Blood type: *

Height *

Weight *

Eye Color *

Natural Hair Color *

Ethnicity (parents country of orgin)

Race

Educational Background

Degree

Major

Occupation *

Previous Occupation*

Do you have health insurance? *

If YES, what type of insurance do you have? List the health insurance company *

Do you smoke? *

Do you drink? How much? *

Do you use drug(s)? *

Marital Status *

Are you sexually active? *

If SINGLE, in steady relationship?

Number of pregnancies *

Number of children *

Any Complications during pregnancy(s)?

Did you have any caesarians?

If yes how many?

Did you have any complications while giving birth?

Did it take more than 6 months for you to concieve any of your pregnancies?

Are you currently breastfeeding? *

Have you ever had a child removed from your home? *

Any medical or psychological problems? *

If YES, please list condition and any medications taken for treatment. *

Have you ever had surgery? *

If YES, please list procedure and date performed. *

Any tattoos or body piercings? *

Have you ever been a surrogate before?

If yes what was the result? *

Have you ever had a sexually transmitted disease?

If so, what was it and when?

Would you be a surrogate for a gay couple or single gay male or female?

Would you be a surrogate for a single heterosexual male?

Would you be a surrogate for a single heterosexual female?

If there was a serious problem with the pregnancy and the prospective parents wanted to

consider abortion, would you be willing to abort?

Do you and your partner understand that, unless you have had a tubal ligation or unless

your partner has had a vasectomy, you must agree to abstain fromsexual activity while attempting to

achieve a pregnancy for the couple?