First and Last Name

Email Address

Address, City, and State

Phone

Cell Phone

How did you hear about us?

What is your height?

What is your weight?

What is your date of birth?

What is your husband or partner's first and last name?

What is your relationship status? (Single, married, divorced, or separated)

How many children have you given birth to?

Do you or does anyone in your house smoke?

On average, how many drinks a week do you consume?

Do you use illicit drugs of any kind?

What prescription drugs are you currently taking?

Are you registered with any Native American tribes?

Do you or your partner or husband have a criminal record of any kind?

What kind of birth control are you currently using?

When was your last pap smear? Was it normal?

Have you ever had an abnormal pap smear? If so, when, and what was the result?

Have you ever tested positive for any sexually transmitted disease?

Have you had more than one sexual partner in the past year?

Will your current partner be willing to be tested for communicable diseases?

Have you ever been diagnosed with clinical depression, bi-polar disorder, or schizophrenia?

Have you ever been diagnosed with any other kind of psychological condition?

Is there any history of sexual abuse in your past?

Highest educational level achieved?

If applicable, what is your college degree in?

Are you currently employed? If so, what is your occupation?

Have you ever placed a child for adoption?

Do you have anyone in your life who would object to or potentially try to prevent a surrogacy?

If you answered "Yes" to the above, please explain.

Are you prepared to take subcutaneous injections daily for as long as necessary (usually through 1st trimester)?

Please list anyone who lives in your home or who spends a lot of time there.

When was your last tattoo?

When was your last piercing?

Do you work with essential oils?

Are you receiving government assistance of any kind (including Medi-Cal)?

If you answered "Yes" to the above, please list any kind of assistance you are on.

Do you have current health insurance? If so, which kind?

Are you a U.S. citizen?

Do you have a reliable vehicle?

Year, make, and model?

Do you have valid auto insurance?

Do you have a valid, current driver’s license?

Is your work/life schedule flexible enough to allow you to make multiple doctor's appointments?

Are you willing to carry twins?

Are you willing to carry triplets?

Are you willing to terminate in the case of a genetic abnormality?

Are you willing to terminate if the doctor recommends termination?

Are you willing to undergo an amniocentesis or other invasive procedure?

What is the name and address of the hospital in which you plan to give birth?

What is the name, address, and phone number of the OB you will see throughout the surrogacy?

Are you willing to provide breast milk for the baby after the birth?

How many times have you been pregnant?

How many C-Sections have you had?

Please include the following information for each of your pregnancies:

Pregnancy #1:

1 - Was there a live birth?

2 - Was it a boy or a girl?

3 - How long was the gestation period (number of weeks you were pregnant)?

4 - What was the weight of the baby?

5 - Were there any complications (high blood pressure, preeclampsia, placenta previa, diabetes, etc.) or anything else we should know?

Pregnancy #2:

1 - Was there a live birth?

2 - Was it a boy or a girl?

3 - How long was the gestation period (number of weeks you were pregnant)?

4 - What was the weight of the baby?

5 - Were there any complications (high blood pressure, preeclampsia, placenta previa, diabetes, etc.) or anything else we should know?

Pregnancy #3:

1 - Was there a live birth?

2 - Was it a boy or a girl?

3 - How long was the gestation period (number of weeks you were pregnant)?

4 - What was the weight of the baby?

5 - Were there any complications (high blood pressure, preeclampsia, placenta previa, diabetes, etc.) or anything else we should know?

Pregnancy #4:

1 - Was there a live birth?

2 - Was it a boy or a girl?

3 - How long was the gestation period (number of weeks you were pregnant)?

4 - What was the weight of the baby?

5 - Were there any complications (high blood pressure, preeclampsia, placenta previa, diabetes, etc.) or anything else we should know?