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Surrogate Eligibility Quiz
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2022-08-31T10:37:13-04:00
Please enable JavaScript in your browser to complete this form.
Answer the questions below to see if you qualify to act as a surrogate!
Are you between the ages of 21 and 44?
*
Yes
No
Are you a US citizen or legal permanent resident?
*
Yes
No
Have you had at least 1 full term (37 weeks) pregnancy without significant complications?
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Yes
No
Have you had less than 6 deliveries?
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Yes
No
Have you had less than 4 C-sections?
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Yes
No
Have you had less than 2 miscarriages?
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Yes
No
Have you had less than 2 stillbirths?
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Yes
No
How tall are you?
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How much do you weigh?
*
Do you have any current/active STDs or STIs?
*
Yes
No
Please specify (not all are disqualifiers):
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Have you suffered from post-partum depression requiring medication?
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Yes
No
Have you taken any medications for mental health purposes (ex. anxiety, depression) within the last 6 months?
*
Yes
No
Are you currently taking them?
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Yes
No
Are you comfortable coming off of them for a surrogacy pregnancy?
*
Yes
No
Do you currently smoke cigarettes or use other tobacco/nicotine products?
*
Yes
No
Have you ever been convicted of a crime?
*
Yes
No
Please specify the crime and the circumstances surrounding the incident:
*
Have you ever been found to have abused or neglected a child?
*
Yes
No
Please describe the incident that led to this finding:
*
Congratulations! It sounds like you would make a great surrogate! PLEASE SUBMIT THIS FORM and we will reach out to your soon to send you some information on surrogacy and to see if you’d like to set up a time to chat about moving forward with surrogacy.
Thank you for taking our surrogate eligibility quiz! Some of your answers require further review before we can let you know whether you will be eligible. PLEASE SUBMIT THIS FORM and we will reach out to you soon to chat about your answers.
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