Do I Qualify?

Answer the questions below to see if you qualify to act as a Surrogate!

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Answer the questions below to see if you qualify to act as a surrogate!

Are you between the ages of 21 and 44? *

Are you a US citizen or legal permanent resident? *

Have you had at least 1 full term (37 weeks) pregnancy without significant complications? *

Have you had less than 6 deliveries? *

Have you had less than 4 C-sections? *

Have you had less than 2 miscarriages? *

Have you had less than 2 stillbirths? *

How tall are you? *

How much do you weigh? *

Do you have any current/active STDs or STIs? *

Please specify (not all are disqualifiers): *

Have you suffered from post-partum depression requiring medication? *

Have you taken any medications for mental health purposes (ex. anxiety, depression) within the last 6 months? *

Are you currently taking them? *

Are you comfortable coming off of them for a surrogacy pregnancy? *

Do you currently smoke cigarettes or use other tobacco/nicotine products? *

Have you ever been convicted of a crime? *

Please specify the crime and the circumstances surrounding the incident: *

Have you ever been found to have abused or neglected a child? *

Please describe the incident that led to this finding: *

Name *

First

Last

Phone *

Email *

State of Residence

1 Marcus Boulevard, Suite 200
Albany, New York 12205
1-866-444-NYSC (6972)
Fax: 518-436-1456
office@NYSurrogacyCenter.com
License Number NYSDOH GS211000

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A BROCHURE
Becoming a Surrogate
Intended Parents