Surrogate Application Form

Thank you for completing our Surrogate Application. We look forward to speaking with you about it soon.

This application contains multiple sections and completing the entire form takes approximately 20 minutes. Please note that the application must be completed all at once and cannot be saved to finish later.

Thanks again for your interest in our program.

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Background Information - Step 1 of 12

Legal Name *

First

Last

Preferred Name/Nickname

Pronouns *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email Address *

Date of Birth *

Social Security Number *

Citizenship Status *

How many years have you lived in that state? *

Highest level of education received *

Do you have a valid driver’s license? *

Do you have a vehicle? *

Do you have access to transportation? *

Do you practice any particular religion? *

What Religion? *

Describe your personality in your own words. *

What are your hobbies/interests? *

What types of stress do you have in your life? *

How do you manage your stress? *

Do you exercise? *

What type? How often? *

Do you smoke cigarettes? *

Have you ever smoked while pregnant? *

Have you ever? *

When did you quit? *

Have you ever smoked while pregnant? *

Does anyone in your household smoke cigarettes? *

Do they smoke in the house? *

Do they smoke in the car with you? *

Do you drink alcohol? *

How often? *

How many drinks? *

Have you ever had a drink while pregnant? *

Do you currently use marijuana? *

How often? *

When was the last time? *

Have you ever used marijuana while pregnant? *

Have you ever? *

When was the last time? *

Have you ever used marijuana while pregnant? *

Does anyone in your household use marijuana? *

Do they smoke in the house? *

Do they smoke in the car with you? *

Do you currently use any illegal drugs? *

What drugs? *

How often? *

When was the last time? *

Have you ever used illegal drugs while pregnant? *

Have you ever? *

What drugs? *

How often? *

When was the last time? *

Have you ever used illegal drugs while pregnant? *

Does anyone in your household use illegal drugs? *

Do you currently use prescription drugs that are not prescribed for you or in amounts beyond what is prescribed for you? *

What drugs? *

How often? *

When was the last time? *

Have you ever used prescription drugs that are not prescribed for you or in amounts beyond what is prescribed for you while pregnant? *

Have you ever? *

What drugs? *

How often? *

When was the last time? *

Have you ever used prescription drugs that are not prescribed for you or in amounts beyond what is prescribed for you while pregnant? (copy) *

Does anyone in your household use prescription drugs that are not prescribed for them or in amounts beyond what is prescribed for them? *

Have you ever been arrested? *

What were you charged with? *

When? *

Describe the incident? *

Were you convicted? *

What crime were you convicted of? *

What was the sentence/penalty imposed? *

Are you currently on probation or parole? *

Have you ever been accused of child abuse or neglect? *

When? *

Describe the circumstances *

What was the outcome? *

Have you ever been a victim of physical abuse, sexual abuse or domestic violence? *

When? *

By whom? *

Describe the circumstances *

Have you ever had an Order of Protection issued to protect you? *

When? *

Against whom? *

Is the Order of Protection still in effect? *

Are there any weapons in your home? *

What kind? *

Where are they kept? *

Are you employed? *

Name of Employer *

Position/Title *

Date this employment started *

Describe your job responsibilities *

Does your job involve physical activity, heavy lifting or substantial time on your feet? *

Please describe *

Current wages (include whether hourly or salary) *

Do you work overtime? *

Overtime pay rate *

Work schedule (include number of hours worked per week) *

Are you able to take time off work to attend medical appointments? *

Do you have a short-term disability policy available through your employer? *

How many employers have you had in the last 10 years?

Selected Value: 0

Have you ever been terminated from a prior employer? *

Reason for termination *

Do you receive any type of public assistance? *

What kind? *

Do you receive any disability benefits? *

Do you receive any workers’ compensation benefits? *

Relationship Status *

Married
Engaged
Committed Relationship
Divorced
Separated
Single

Spouse’s Full Legal Name *

First

Middle

Last

Spouse’s Preferred Name/Nickname

Spouse's Pronouns *

Spouse's Phone Number *

Spouse's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Spouse's Email Address *

Spouse's Date of Birth *

Date of Marriage *

Is your spouse employed? *

Occupation *

Current wages (include whether hourly or salary) *

Do they work overtime? *

Overtime pay rate *

Has your spouse ever been arrested? *

What were the charges? *

When? *

Describe the incident *

Were they convicted? *

What crime were they convicted of? *

What was the sentence/penalty imposed? *

Are they currently on probation or parole? *

Has your spouse been accused of child abuse or neglect? *

When? *

Describe the circumstances *

What was the outcome? *

Is your spouse fully vaccinated for Covid-19? *

Fiancé’s Full Legal Name *

First

Middle

Last

Fiancé’s Preferred Name/Nickname

Fiancé's Pronouns *

Fiancé’s Phone Number *

Fiancé’s Address *

Address Line 1

Address Line 2

City

State

Zip Code

Fiancé’s Email Address *

Fiancé’s Date of Birth *

Anticipated Date of Marriage *

Is your fiancé employed? *

Occupation *

Current wages (include whether hourly or salary) *

Do they work overtime? *

Overtime pay rate *

Has your fiancé ever been arrested? *

What were the charges? *

When? *

Describe the incident *

Were they convicted? *

What crime were they convicted of? *

What was the sentence/penalty imposed? *

Are they currently on probation or parole? *

Has your fiancé been accused of child abuse or neglect? *

When? *

Describe the circumstances *

What was the outcome? *

Is your fiancé fully vaccinated for Covid-19? *

Partner's Full Legal Name *

First

Middle

Last

Partner's Preferred Name/Nickname

Pronouns *

Partner's Phone Number *

Partner's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Partner's Email Address *

Partner's Date of Birth *

Is your partner employed? *

Occupation *

Current wages (include whether hourly or salary) *

Do they work overtime? *

Overtime pay rate *

Has your partner ever been arrested? *

What were the charges? *

When? *

Describe the incident *

Were they convicted? *

What crime were they convicted of? *

What was the sentence/penalty imposed? *

Are they currently on probation or parole? *

Has your partner been accused of child abuse or neglect? *

When? *

Describe the circumstances *

What was the outcome? *

Is your partner fully vaccinated for Covid-19? *

Date of Divorce *

Do you have a separation agreement or a judgment of separation? *

Have you lived apart for at least 3 years? *

Do you have your own children? *

How many?

Selected Value: 0

What are their ages? *

Were any of your children adopted? *

Is there anyone else living in your household? *

Name, Age, Relationship to you for each *

Height *

Weight *

Are you currently taking any prescription medications? *

What medication? *

For what purpose? *

List all other prescription medications you’ve taken in the last 10 years, the dates you took them and the purpose for each *

Are you currently breastfeeding? *

When do you plan to stop? *

Have you ever had a surgery other than a C-section? *

List each surgery, when it occurred, and specify & describe any complications *

Have you ever been hospitalized other than for delivery of a baby? *

What for and when? *

Have you ever had a major illness? *

What illness and when? *

Have you ever had a Hepatitis B vaccine? *

Have you been fully vaccinated for COVID-19? *

Are you willing to get vaccinated if recommended by the fertility clinic? *

Are you willing to get boosters if recommended by the fertility clinic? *

Have you had COVID-19? *

When? *

Have you received a flu vaccine this year? *

Are you willing to receive a flu vaccine if recommended by the fertility clinic? *

Are you willing to receive the TDAP vaccine during pregnancy, if requested by the intended parent(s)? *

Have you ever been diagnosed with any of the following? *

Endometriosis
Thyroid problems
Back pain
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice
Hepatomegaly
Icterus
Smallpox
Vaccinia necrosum
Vaccinia keratitis
Hepatitis B
None of the above

Have you ever had an adverse reaction to anesthesia? *

Please describe the reaction *

Have you traveled outside the continental United States in the last 12 months? *

List all countries you traveled to *

Has your spouse/significant other traveled outside the continental United States in the last 12 months? *

List all countries they traveled to *

Have you ever been tested for HIV/AIDS? *

When and what was the result? *

Have you ever had any type of STD or STI? *

When? What type? Describe any treatment you received. *

Would you be willing to submit to an HIV/STD screening and share the results with the Intended Parents? *

Does your spouse or significant other have ay STDs or STIs? *

What type? *

How many sexual partners have you had in the last year? *

Do any of these partners have STDs or STIs? *

Do you currently engage in protected sex? *

What type of protection do you use? *

Do you currently use contraception? *

What type? *

Have you ever used a needle to take drugs? *

Have you ever had a sexual partner who used a needle to take drugs? *

Have you had a tattoo or body piercing within the last 12 months? *

When? *

Have you ever had a blood transfusion? *

When? *

Do you have any other medical diagnosis? *

What diagnosis? When were you diagnosed? Describe current status or treatment plan. *

Have you ever seen a therapist or other mental health professional? *

For what period of time and for what purpose? *

Have you ever taken any medications for mental health purposes (e.g., anxiety, depression, mood disorders, personality disorders, etc.)? *

Which medications, for what period of time, and for what purpose? *

Have you ever received a mental health diagnosis? *

What was the diagnosis or diagnoses and when did you receive it? *

Have you ever suffered from an eating disorder? *

Describe the circumstances. *

Have you ever suffered from postpartum depression? *

Describe the circumstances and when it occurred. *

Would you describe any portion of your prior pregnancies or post-partum periods as traumatic? *

Please describe. *

What was the date of your last pap smear? *

Please list the name and address of the medical practice where you had your last pap smear. *

Was your last paper smear abnormal? *

Please describe. *

Age at first period? *

What is the duration of your menstrual cycle? (Example: 28 days) *

What is the duration of your menses? (Example: 5 days) *

Do you experience any bleeding between your menses? *

Please describe. *

Have you ever seen a fertility doctor? *

Please include the name of the doctor, when you saw him or her, and the reason for the appointments. *

Have you ever been told you were infertile? *

What was the cause of the infertility? *

Have you ever been a surrogate before? *

How many times?

Selected Value: 0

Please list the names and addresses of any fertility clinics you received care from during a prior surrogacy journey. *

Have you ever applied and been denied to be an egg donor or surrogate? *

When? Where did you apply? What was the reason for denial? *

You will need to provide information regarding each of your prior pregnancies, including pregnancies that resulted in live birth, miscarriage, stillbirth, and/or abortion. Please list each pregnancy separately.

Answer the following questions for your MOST RECENT pregnancy.

Did you conceive naturally (i.e., without medical intervention)? *

What type of medical assistance did you receive? (e.g., fertility drugs, IVF, artificial insemination, etc.)? *

Was it a singleton or multiple (ex. twins) pregnancy? *

Singleton
Multiple

What was the result of the pregnancy? *

Live Birth
Miscarriage
Sillbirth
Abortion

Date of Delivery *

How many weeks pregnant were you when you delivered? *

Did you have any complications during pregnancy? *

Describe the complications. *

How much weight did you gain during the pregnancy? *

Was your delivery vaginal or C-section? *

Vaginal
C-section

What was the birth weight of the child? *

List any birth defects or other issues. *

Does your child have any medical conditions or disabilities? *

Describe: *

Did you receive prenatal care? *

What week of your pregnancy were you first seen by a prenatal care provider? *

Did you ever skip any prenatal appointments or recommended testing? *

Please list the name and address of the hospital or birthing center where you delivered. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Cause (if known): *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Cause (if known): *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Reason *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

Did you experience any of the following during your pregnancy? *

Gestational diabetes
Preeclampsia
Placental abruption
Placenta previa
Umbilical cord prolapse
Placenta accreta
High or low amniotic fluid levels
Incompetent cervix
Hyperemesis gravidarum (extreme morning sickness)
HELLP syndrome
Ectopic pregnancy
Cholestasis
Cervical cerclage
Blighted ovum
Blood clots during pregnancy
High blood pressure during pregnancy
Bedrest during pregnancy
Restricted physical activity during pregnancy
None of the above

Did you have any prior pregnancies? *

What hospital would you prefer to use for your surrogacy delivery? *

Did you conceive naturally (i.e., without medical intervention)? *

What type of medical assistance did you receive? (e.g., fertility drugs, IVF, artificial insemination, etc.)? *

Was it a singleton or multiple (ex. twins) pregnancy? *

Singleton
Multiple

What was the result of the pregnancy? *

Live Birth
Miscarriage
Sillbirth
Abortion

Date of Delivery *

How many weeks pregnant were you when you delivered? *

Did you have any complications during pregnancy? *

Describe the complications. *

How much weight did you gain during the pregnancy? *

Was your delivery vaginal or C-section? *

Vaginal
C-section

What was the birth weight of the child? *

List any birth defects or other issues. *

Does your child have any medical conditions or disabilities? *

Describe: *

Did you receive prenatal care? *

What week of your pregnancy were you first seen by a prenatal care provider? *

Did you ever skip any prenatal appointments or recommended testing? *

Please list the name and address of the hospital or birthing center where you delivered. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Cause (if known): *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Cause (if known): *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Reason *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

Did you experience any of the following during your pregnancy? *

Gestational diabetes
Preeclampsia
Placental abruption
Placenta previa
Umbilical cord prolapse
Placenta accreta
High or low amniotic fluid levels
Incompetent cervix
Hyperemesis gravidarum (extreme morning sickness)
HELLP syndrome
Ectopic pregnancy
Cholestasis
Cervical cerclage
Blighted ovum
Blood clots during pregnancy
High blood pressure during pregnancy
Bedrest during pregnancy
Restricted physical activity during pregnancy
None of the above

Did you have any prior pregnancies? *

What hospital would you prefer to use for your surrogacy delivery? *

Did you conceive naturally (i.e., without medical intervention)? *

What type of medical assistance did you receive? (e.g., fertility drugs, IVF, artificial insemination, etc.)? *

Was it a singleton or multiple (ex. twins) pregnancy? *

Singleton
Multiple

What was the result of the pregnancy? *

Live Birth
Miscarriage
Sillbirth
Abortion

Date of Deliver *

How many weeks pregnant were you when you delivered? *

Did you have any complications during pregnancy? *

Describe the complications. *

How much weight did you gain during the pregnancy? *

Was your delivery vaginal or C-section? *

Vaginal
C-section

What was the birth weight of the child? *

List any birth defects or other issues. *

Does your child have any medical conditions or disabilities? *

Describe: *

Did you receive prenatal care? *

What week of your pregnancy were you first seen by a prenatal care provider? *

Did you ever skip any prenatal appointments or recommended testing? *

Please list the name and address of the hospital or birthing center where you delivered. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Cause (if known): *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Cause (if known): *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Reason *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

Did you experience any of the following during your pregnancy? *

Gestational diabetes
Preeclampsia
Placental abruption
Placenta previa
Umbilical cord prolapse
Placenta accreta
High or low amniotic fluid levels
Incompetent cervix
Hyperemesis gravidarum (extreme morning sickness)
HELLP syndrome
Ectopic pregnancy
Cholestasis
Cervical cerclage
Blighted ovum
Blood clots during pregnancy
High blood pressure during pregnancy
Bedrest during pregnancy
Restricted physical activity during pregnancy
None of the above

Did you have any prior pregnancies? *

What hospital would you prefer to use for your surrogacy delivery? *

Did you conceive naturally (i.e., without medical intervention)? *

What type of medical assistance did you receive? (e.g., fertility drugs, IVF, artificial insemination, etc.)? *

Was it a singleton or multiple (ex. twins) pregnancy? *

Singleton
Multiple

What was the result of the pregnancy? *

Live Birth
Miscarriage
Sillbirth
Abortion

Date of Delivery *

How many weeks pregnant were you when you delivered? *

Did you have any complications during pregnancy? *

Describe the complications. *

How much weight did you gain during the pregnancy? *

Was your delivery vaginal or C-section? *

Vaginal
C-section

What was the birth weight of the child? *

List any birth defects or other issues. *

Does your child have any medical conditions or disabilities? *

Describe: *

Did you receive prenatal care? *

What week of your pregnancy were you first seen by a prenatal care provider? *

Did you ever skip any prenatal appointments or recommended testing? *

Please list the name and address of the hospital or birthing center where you delivered. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Cause (if known): *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Cause (if known): *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Reason *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

Did you experience any of the following during your pregnancy? *

Gestational diabetes
Preeclampsia
Placental abruption
Placenta previa
Umbilical cord prolapse
Placenta accreta
High or low amniotic fluid levels
Incompetent cervix
Hyperemesis gravidarum (extreme morning sickness)
HELLP syndrome
Ectopic pregnancy
Cholestasis
Cervical cerclage
Blighted ovum
Blood clots during pregnancy
High blood pressure during pregnancy
Bedrest during pregnancy
Restricted physical activity during pregnancy
None of the above

Did you have any prior pregnancies? *

What hospital would you prefer to use for your surrogacy delivery? *

Did you conceive naturally (i.e., without medical intervention)? *

What type of medical assistance did you receive? (e.g., fertility drugs, IVF, artificial insemination, etc.)? *

Was it a singleton or multiple (ex. twins) pregnancy? *

Singleton
Multiple

What was the result of the pregnancy? *

Live Birth
Miscarriage
Sillbirth
Abortion

Date of Delivery *

How many weeks pregnant were you when you delivered? *

Did you have any complications during pregnancy? *

Describe the complications. *

How much weight did you gain during the pregnancy? *

Was your delivery vaginal or C-section? *

Vaginal
C-section

What was the birth weight of the child? *

List any birth defects or other issues. *

Does your child have any medical conditions or disabilities? *

Describe: *

Did you receive prenatal care? *

What week of your pregnancy were you first seen by a prenatal care provider? *

Did you ever skip any prenatal appointments or recommended testing? *

Please list the name and address of the hospital or birthing center where you delivered. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Cause (if known): *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Cause (if known): *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Reason *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

Did you experience any of the following during your pregnancy? *

Gestational diabetes
Preeclampsia
Placental abruption
Placenta previa
Umbilical cord prolapse
Placenta accreta
High or low amniotic fluid levels
Incompetent cervix
Hyperemesis gravidarum (extreme morning sickness)
HELLP syndrome
Ectopic pregnancy
Cholestasis
Cervical cerclage
Blighted ovum
Blood clots during pregnancy
High blood pressure during pregnancy
Bedrest during pregnancy
Restricted physical activity during pregnancy
None of the above

Did you have any prior pregnancies? *

What hospital would you prefer to use for your surrogacy delivery? *

Did you conceive naturally (i.e., without medical intervention)? *

What type of medical assistance did you receive? (e.g., fertility drugs, IVF, artificial insemination, etc.)? *

Was it a singleton or multiple (ex. twins) pregnancy? *

Singleton
Multiple

What was the result of the pregnancy? *

Live Birth
Miscarriage
Sillbirth
Abortion

Date of Delivery *

How many weeks pregnant were you when you delivered? *

Did you have any complications during pregnancy? *

Describe the complications. *

How much weight did you gain during the pregnancy? *

Was your delivery vaginal or C-section? *

Vaginal
C-section

What was the birth weight of the child? *

List any birth defects or other issues. *

Does your child have any medical conditions or disabilities? *

Describe: *

Did you receive prenatal care? *

What week of your pregnancy were you first seen by a prenatal care provider? *

Did you ever skip any prenatal appointments or recommended testing? *

Please list the name and address of the hospital or birthing center where you delivered. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Cause (if known): *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Cause (if known): *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Reason *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

Did you experience any of the following during your pregnancy? *

Gestational diabetes
Preeclampsia
Placental abruption
Placenta previa
Umbilical cord prolapse
Placenta accreta
High or low amniotic fluid levels
Incompetent cervix
Hyperemesis gravidarum (extreme morning sickness)
HELLP syndrome
Ectopic pregnancy
Cholestasis
Cervical cerclage
Blighted ovum
Blood clots during pregnancy
High blood pressure during pregnancy
Bedrest during pregnancy
Restricted physical activity during pregnancy
None of the above

Did you have any prior pregnancies? *

What hospital would you prefer to use for your surrogacy delivery? *

Did you conceive naturally (i.e., without medical intervention)? *

What type of medical assistance did you receive? (e.g., fertility drugs, IVF, artificial insemination, etc.)? *

Was it a singleton or multiple (ex. twins) pregnancy? *

Singleton
Multiple

What was the result of the pregnancy? *

Live Birth
Miscarriage
Sillbirth
Abortion

Date of Delivery *

How many weeks pregnant were you when you delivered? *

Did you have any complications during pregnancy? *

Describe the complications. *

How much weight did you gain during the pregnancy? *

Was your delivery vaginal or C-section? *

Vaginal
C-section

What was the birth weight of the child? *

List any birth defects or other issues. *

Does your child have any medical conditions or disabilities? *

Describe: *

Did you receive prenatal care? *

What week of your pregnancy were you first seen by a prenatal care provider? *

Did you ever skip any prenatal appointments or recommended testing? *

Please list the name and address of the hospital or birthing center where you delivered. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Cause (if known): *

Date *

List other complications during pregnancy. *

How many weeks pregnant were you? *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

Cause (if known): *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

How many weeks pregnant were you? *

Reason *

Date *

List other complications during pregnancy. *

Please list the name and address of the OBGYN or Midwife you used during this pregnancy. *

Did you experience any of the following during your pregnancy? *

Gestational diabetes
Preeclampsia
Placental abruption
Placenta previa
Umbilical cord prolapse
Placenta accreta
High or low amniotic fluid levels
Incompetent cervix
Hyperemesis gravidarum (extreme morning sickness)
HELLP syndrome
Ectopic pregnancy
Cholestasis
Cervical cerclage
Blighted ovum
Blood clots during pregnancy
High blood pressure during pregnancy
Bedrest during pregnancy
Restricted physical activity during pregnancy
None of the above

Are you willing to sign a release for your full medical records to be turned over to the Intended Parents or their agent(s) to review prior to being selected as a surrogate? *

Would you be willing to undergo a comprehensive physical exam and take any test requested by the Intended Parents or recommended by the medical professionals examining you and share the results with the Intended Parents? *

Would you be willing to undergo a comprehensive mental health screening and share the results with the Intended Parents? *

Do you have health insurance? *

Who do you have your insurance through? *

Your employer
Your spouse's employer
Marketplace
Medicaid

What type of plan do you have? *

Individual
Family
Individual + spouse
individual + child(ren)

Do you have disability insurance? *

Do you have disability insurance available either through your employer or your spouse’s employer? *

Yes
No
Unknown

What would you like Intended Parents to know about your motivation for pursuing surrogacy (this will be used in your surrogate profile)? *

Rank your motivations using 1 for your highest motivation and 3 for your lowest motivation. Please uniquely rank each motivation (don't reuse numbers). (copy) *

	1	2	3
Enjoy being pregnant and don’t intend to have more children	1Enjoy being pregnant and don’t intend to have more children 1	2Enjoy being pregnant and don’t intend to have more children 2	3Enjoy being pregnant and don’t intend to have more children 3
Want to help give a family a child	1Want to help give a family a child 1	2Want to help give a family a child 2	3Want to help give a family a child 3
Need/want the compensation	1Need/want the compensation 1	2Need/want the compensation 2	3Need/want the compensation 3

Have you talked to your spouse/significant other about your desire to be a surrogate? *

Are they supportive? *

Why not? *

Have you talked to your child or children about being a surrogate? *

What was or were their reaction(s)? *

Why not? *

Who will be your primary support system(s) during the surrogacy process? *

Would you be willing to pump, freeze and ship breast milk to the Intended Parents? *

Describe your ideal Intended Parents (this will be used in your surrogate profile). *

Do you prefer to work with Intended Parents who are fully vaccinated for COVID-19? *

Yes
No
No Preference

Would you be willing to be a surrogate in the following cases? *

	Yes	No
Using donated egg	YesUsing donated egg Yes	NoUsing donated egg No
Using donated sperm	YesUsing donated sperm Yes	NoUsing donated sperm No
Using donated embryo	YesUsing donated embryo Yes	NoUsing donated embryo No
Married intended parents	YesMarried intended parents Yes	NoMarried intended parents No
Non-married intended parents	YesNon-married intended parents Yes	NoNon-married intended parents No
Opposite-sex couple	YesOpposite-sex couple Yes	NoOpposite-sex couple No
Same-sex male couple	YesSame-sex male couple Yes	NoSame-sex male couple No
Same-sex female couple	YesSame-sex female couple Yes	NoSame-sex female couple No
Transgender/non-binary intended parent(s)	YesTransgender/non-binary intended parent(s) Yes	NoTransgender/non-binary intended parent(s) No
Single woman	YesSingle woman Yes	NoSingle woman No
Single man	YesSingle man Yes	NoSingle man No
Intended parents who are intentionally trying for multiples (twins)	YesIntended parents who are intentionally trying for multiples (twins) Yes	NoIntended parents who are intentionally trying for multiples (twins) No
Intended parents over 50	YesIntended parents over 50 Yes	NoIntended parents over 50 No
Intended parents with existing children	YesIntended parents with existing children Yes	NoIntended parents with existing children No
Intended parents who are biologically able to have their own children	YesIntended parents who are biologically able to have their own children Yes	NoIntended parents who are biologically able to have their own children No
Intended parents residing in another state	YesIntended parents residing in another state Yes	NoIntended parents residing in another state No
Intended parents residing in another country	YesIntended parents residing in another country Yes	NoIntended parents residing in another country No

Would you allow the intended parents to be involved during the pregnancy? *

Would you allow the intended parents to attend medical appointments with you? *

Would you allow the intended parents to be in the delivery room? *

Would you allow the intended parents to visit you at your home? *

Are you opposed to the intended parents selecting the gender of the embryo? *

How many embryo transfer procedures are you willing to undergo in the event the first transfer is not successful? *

Are you willing to terminate a pregnancy at the intended parents’ request in any of the following situations? *

	Yes	No
Unlikely that pregnancy will be successful	YesUnlikely that pregnancy will be successful Yes	NoUnlikely that pregnancy will be successful No
Unlikely that child will be born alive	YesUnlikely that child will be born alive Yes	NoUnlikely that child will be born alive No
Unlikely that child would survive for a substantial period after birth	YesUnlikely that child would survive for a substantial period after birth Yes	NoUnlikely that child would survive for a substantial period after birth No
Child will have severe physical disabilities	YesChild will have severe physical disabilities Yes	NoChild will have severe physical disabilities No
Child will have severe physical deformities	YesChild will have severe physical deformities Yes	NoChild will have severe physical deformities No
Child will have severe mental or intellectual disabilities	YesChild will have severe mental or intellectual disabilities Yes	NoChild will have severe mental or intellectual disabilities No

Are you willing to carry multiples (twin) as long as your health and the health of the babies is not at risk? *

Are you willing to undergo a transfer of more than one embryo at a time to intentionally try for twins? *

Are you willing to transfer more than one embryo at a time based on medical recommendation due to low quality embryos? *

Are you willing to selectively reduce multiples at the intended parents’ request, even if all babies could be born healthy in the following scenarios? *

	Yes	No
Reduce triples to twins	YesReduce triples to twins Yes	NoReduce triples to twins No
Reduce twins to singleton	YesReduce twins to singleton Yes	NoReduce twins to singleton No

If bed rest was recommended, would you be able to follow that recommendation? *

If limits on physical activity were recommended, would you be able to follow that recommendation? *

On a scale of 1 to 10, with 1 being the least confident and 10 being the most confident, how confident are you that you would be able to turn the baby over to the intended parents after the birth?

Selected Value: 0

Do you want more children of your own? *

Do you want contact with the intended parents and/or the child after the birth? *

What type of contact? How frequently?

If the process goes well, would you be willing to be a surrogate for the same intended parents again in the future? *

Is all of the information contained in this application true and accurate to the best of your knowledge? *

Do you agree to notify New York Surrogacy Center if any of the information in this application becomes incorrect or incomplete? *

Do you understand that the information provided in this application will be used by New York Surrogacy Center to determine whether you meet the eligibility requirements to act as a surrogate? *

Do you understand that there is no guarantee that you will be approved by New York Surrogacy Center to act as a surrogate and that New York Surrogacy Center retains ultimate discretion in selecting surrogates for approval? *

Do you authorize New York Surrogacy Center to show this application and/or share the information contained herein with intended parents as part of the matching process? *

Do you authorize New York Surrogacy Center to show this application and/or share the information contained herein with third parties as necessary to facilitate the surrogacy process, including but not limited to fertility clinics, medical and/or psychological evaluators, insurance agents, escrow agents and/or attorneys for the parties? *

In case NYSC has any promotional materials to send out, what size T-shirt would you prefer? *

Small
Medium
Large
X-Large