Now, complete your final application below.

Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

Are you a U.S. Citizen? *

Yes

No

Are you active military or reserve? *

Yes

No

Is your partner/spouse or any adult living in your home active military or reserve? *

Yes

No

Have you ever been a gestational carrier, surrogate, and/or egg donor? *

Yes, I have been a gestational carrier/surrogate.

Yes, I have been an egg donor.

Yes, I have been a gestational carrier/surrogate and egg donor.

No, I have not.

Do you have legal and physical custody of all of your children? *

Joint custody is OK for this question.

Yes

No

Are you, your partner/spouse, or any members of your family registered members of a Native American tribe? *

Yes

No

Are you or any of your household family members on any form of government assistance? *

WIC, Medicaid, Food Stamps, SNAP, etc.

Yes

No

Do you have health insurance? *

Yes

No

Did you graduate high school? *

Yes

No

Did you attend any secondary education/university? *

Yes

No

Besides you and your spouse/partner, are there any adults age 18 and older living in your home? *

Yes

No

Have you ever had a c-section? *

Yes

No

Have you ever had any complications during any pregnancies or deliveries? *

(Gestational diabetes, preeclampsia, issues during delivery, etc.)

Yes

No

Are you currently breastfeeding? *

Yes

No

Have you ever been referred by your OB/GYN to a specialist (i.e. fertility doctor or maternal/fetal “high risk” OB? *

Yes

No

Have you ever been advised not to become pregnant? *

(I.e. too risky, too soon after another pregnancy, etc.)

Yes

No

Have you ever been medically evaluated for surrogacy or egg donation and been declined? *

Yes

No

Have you ever had a psychological evaluation for surrogacy or egg donation? *

Yes

No

Are you currently using birth control? *

Yes

No

Did you need any medical assistance to conceive your children? *

Yes

No

The fertility clinics we work with have both male and female doctors/practitioners. Do you have any issues being treated by a male doctor/practitioner? *

Yes

No

Do you, or have you ever smoked? *

Yes

No

Have you ever smoked during any pregnancy? *

Yes

No

Have you or anyone in your household ever received treatment for drug and/or alcohol abuse? *

Yes

No

Do you or anyone in your household use any drugs, narcotics or otherwise, including marijuana? *

Yes

No

Have you ever been under the care of a psychiatrist? *

(Hospitalization, medication, on-going therapy, etc.)

Yes

No

Have you ever experienced depression or other mental illness? *

Yes

No

Has anyone in your household ever experienced depression or other mental illness? *

Yes

No

Have you or any member of your family ever attempted suicide? *

Yes

No

Have you or anyone in your household ever been accused of/ charged with /arrested for and/or convicted of a crime? *

Yes

No

Have you been vaccinated against COVID-19, or are you willing to be before becoming pregnant? *

Yes, I am fully vaccinated

No, but I plan to be

No, but I am open to discussing this further

No, and I do not plan to be

Do you want to have any more children of your own? *

Yes

No

Are there any types of parents you are NOT willing to be a gestational carrier for?

Single Man (Gay or Straight)

Single Woman (Gay or Straight)

Married Straight Couple

Gay Male Couple

Lesbian Couple

HIV Positive

Transgender Individuals

Parent(s) Older than 50

Are you willing to carry twins? *

Yes

No

Are you comfortable with the various medications required of the surrogacy process, including daily injections? *

We will provide you with full details on these medications and the process during our one-on-one meeting.

Yes

No

Do you have any travel planned in the next 12 months that is more than 3 hours drive from your home AND/OR that is is outside of the USA? *

Yes

No

Do you have your own car and valid drivers license for transportation to appointments, meetings, etc.? *

Yes

No