Name
*
First Name
Last Name
Email
*
Phone
*
Country
(###)
###
####
How did you know us
*
Facebook /INS Ads
Google Ads
Tiktok Ads
Friend referral
Others
Race
*
Asian
African American
Latino
Native American
Pacific Islander
Non-Hispanic White
Two or more races
Other
Blood Type
*
A
AB
B
O
I don't know.
Birthday
*
MM
DD
YYYY
Height
*
Weight
*
Hair Color
*
Black
Brown
Blonde
Auburn
Red
Other
Eye Color
*
Amber
Blue
Brown
Gray
Green
Hazel
Other
Ethnicity
*
Asian
Arab
Black/Africa-descent
Hispanic/Latino
Native American
Pacific Islander
White/European
Others
Where were you born?
*
What is your current residential address?
*
Occupation
*
What is the highest education you have?
What was your major in your highest degree?
What is your current marital status?
*
Single
Married
Divorced
Separated
Long-term boyfriend
Long-term girlfriend
If you are married, your husband/partner's name?
*
What is the primary source of income for your family?
*
How many biological children do you have?
*
Are all of your children living with you?
*
Are you currently parenting at least one of your biological children?
*
Yes
No
N/A
Do you have legal custody of your children?
*
Yes
No
N/A
Are you considering expanding your own family in the future?
*
Yes
No
N/A
Apart from your children and partner, are there any other individuals living in your home?
*
Yes
No
Have you or your partner ever been subject to an investigation by a child protection agency?
*
Yes
No
Are you or your partner currently involved in any legal proceedings or claims?
*
Have you or your partner ever been involved in any lawsuit?
*
Have you or your partner ever been arrested? (including DUI arrests)
*
Have you or your partner, if applicable ,ever had psychological counseling?
*
Yes
No
Please describe your personality traits.
*
What does your daily routine consist of?
*
What activities do you enjoy outside of work/school?
*
Please describe your living environment, including the type of housing, community safety, neighborhood relationships, etc.
*
What is your favorite way to spend time with your family?
*
How often do you engage in physical activity?
*
Do you have an existing health insurance policy?
*
Yes
No
Do you consume alcohol? If yes, please specify the number of drinks per week?
*
Do you smoke?
*
Yes
No
Do you encounter any second-hand smoke in your living or working environment?
*
Yes
No
Have you ever consumed any prohibited substances? If yes, what did you use and when was the last time? ( please note that you will be tested)
*
Do you use recreational drugs? If yes, please list the drugs you use and their frequency of use.
*
Are you aware of any genetic disorders in your family?
*
Do you take any medication regularly?
*
Do you have any past or current medical issues?
*
Are you allergic to any medication?
*
Have you ever been prescribed any psychiatric medications in the past 5 years? (including anti-depressants and anti-anxiety medications)
*
Have you had any surgeries?
*
Have you ever been diagnosed with any of following?
*
TB/exposed to TB, Cancer, Irregular Heartbeat, Heart problems / congenital, Heart defect, Head injuries, Thyroid, Problems, Seizures, Anemia, Genital Warts Chlamydia, Gonorrhea, Genital Herpes, Syphilis, HIV, Hepatitis B Hepatitis C, Ovarian Cysts, HPV
Have you been vaccinated for covid-19?
*
Yes
No
Have you ever been hospitalized for psychiatric care?
*
Yes
No
Have you ever attempted suicide?
*
Yes
No
What is your current birth control method?
*
Have you ever had any miscarriages? This excludes any chemical pregnancies (where the heartbeat was never detected)
*
Yes
No
When was your last menstrual period?
*
MM
DD
YYYY
What is the duration of your menstrual cycle?
*
Was your first pregnancy a personal one or part of a surrogacy journey?
*
Myself
Surrogacy
Date of your first delivery
*
MM
DD
YYYY
Any complications? If yes, what it was?
*
Weeks of Gestation.
*
Number of babies delivered?
*
What was the method of your baby’s delivery?
*
Vaginal
C-section
The weight of your newborn.
*
Gender of your first child(ren).
*
Male
Female
Other
Was your second pregnancy a personal one or part of a surrogacy journey?
Myself
Surrogacy
Date of your SECOND delivery
MM
DD
YYYY
Any complications? If yes, what it was?
Weeks of Gestation.
Number of babies delivered?
What was the method of your baby’s delivery?
Vaginal
C-section
The weight of your newborn.
Gender of your second child(ren).
Male
Female
Other
Was your third pregnancy a personal one or part of a surrogacy journey?
Myself
Surrogacy
Date of your third delivery
MM
DD
YYYY
Any complications? If yes, what it was?
Weeks of Gestation.
Number of babies delivered?
What was the method of your baby’s delivery?
Vaginal
C-section
The weight of your newborn.
Gender of your third child(ren).
Male
Female
Other
Kindly tell us the dates, and details of any further deliveries, including the weight(s) of the newborn(s),gender,delivery gestational weeks and C-section or not.
Have you experienced an abortion? If Yes, how many ?
*
Are you still breastfeeding if you've delivered a newborn within the past year? If Yes, when will you stop?
*
Why do you want to become a surrogate?
*
What information would you like the Intended Parents know about you?
*
What kind of relationship would you like with your IP's during your surrogacy journey? (friendship, very little to NO communication)
*
Would you be comfortable with the IP's in the delivery room?
*
Yes
No
Would you be comfortable with the IP's in the delivery room?
*
Yes
No
Would you be willing to pump after delivery? (you will be paid well)
*
Yes
No
Are you comfortable having the IP in the transfer room/or recording the transfer for the IP?
*
Yes
No
Are you open to work with HIV + intended parents ? (The embryo is clean and healthy, and the doctor will provide you with further detail.)
*
Yes
No
Are you willing to work with intended parents who have Hepatitis B? (The embryo is clean and you will be fully protected by HBV Vaccine)
Yes
No
Are you willing to work with single intended parent?
Yes
No
Are you willing to working with same-sex intended parents?
Yes
No
Can you identify at least two individuals who are part of your support network? what type of relationship it is?
*
Have you ever been a surrogate or egg donor before? If yes, how many times?
*
When would you prefer to start your journey towards surrogacy?
*
Right away
In 3 months
Other
Are you prepared to attend all of your local medical appointments?
*
Yes
No
Would it be possible for you to travel out of state for a duration of 2-3 days, given that your travel expenses, childcare, and lost wages are covered?
*
Yes
No
In what situations would you contemplate the possibility of ending a pregnancy? For instance, upon medical advice, for selective reduction, or due to severe abnormalities?
*
During this surrogacy journey, how many babies are you comfortable with carrying?
*
By typing your FULL NAME, you are authorizing the release of your information, including medical details, to both the clinic and intended parents. This release is exclusively for medical and surrogacy matching purposes. We assure full compliance with all federal and California state laws governing this matter.
*
