Surrogate Application

Are you able to attend all local appointments?

Yes

No

Are you actively parenting at least one of your own children?

Yes

No

How soon would you like to begin your Surrogacy journey?

Right away

6 months

1 year

Have you ever applied to any other agencies as a surrogate or egg donor? (if yes what agency?)

Yes

No

Are there any other people residing in your home other than your children? or your partner?

Yes

No

Are you able to travel out of state for 2-3 days? If travel expenses including childcare and lost wages are reimbursed?

Yes

No

Do you have an existing health insurance policy?

Yes

No

Do you drink alcoholic beverages?

Yes

No

Have you or your partner ever been investigated by governmental child protective agency?

Yes

No

Do you or your partner currently have any legal cases or claims pending?

Yes

No

Have you or your partner ever been involved in any lawsuit?

Yes

No

Have you ever used illicit drugs (marijuana, cocaine, methamphetamines)?

Yes

No

Are you exposed to any second-hand smoke at home or at work?

Yes

No

Have you or your partner ever been arrested? (including DUI arrests)

Yes

No

Have you ever been a surrogate or egg donor before?

Yes

No

Are all of your children living with you currently?

Yes

No

Do you have legal custody of your children?

Yes

No

Do you plan on having more children of your own?

Yes

No

Do you have a regular menstrual cycle?

Yes

No

Do you have any past or current medical issues?

Yes

No

Are you allergic to any medication?

Yes

No

Have you ever been prescribed any medications in the last 5 years?

Yes

No

Have you had any surgeries?

Yes

No

Have you ever had any miscarriages? This excludes any chemical pregnancies (where the heartbeat was never detected)

Yes

No

Have you had any abortions?

Yes

No

Have you been vaccinated for covid-19?

Yes

No

Was this pregnancy for yourself or a surrogacy journey?

Myself

Surrogacy journey

Any complications?

Yes

No

Vaginal or C-section?

Yes

No

Was this pregnancy for yourself or a surrogacy journey?

Myself

Surrogacy journey

Any complications?

Yes

No

Have you or your partner if applicable ever had psychological counseling?

Yes

No

Have you ever been prescribed any psychiatric medications? (including anti-depressants and anti-anxiety medications)

Yes

No

Have you ever been hospitalized for psychiatric care?

Yes

No

Have you ever attempted suicide?

Yes

No

Would you be comfortable with the IP's in the delivery room?

Yes

No

Would you be willing to pump after delivery?

Yes

No

Are you comfortable having the IP in the transfer room/or recording the transfer for the IP?

Yes

No

Are you comfortable with injections and taking oral medication for surrogacy?

Yes

No