Gestational Surrogate Application

1Personal Information
2Additional Pre-Qualifying

Please answer all questions in a truthful and factual manner to the best of your ability. All identifying information will be kept confidential and will not be released to potential recipients without your permission.

First Name

Last Name

Maiden Name (if applicable)

Street Address

Street Address Line 2

City

State

Zip

Email Address

Phone Number

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Agree

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

What is your communication preference? (select all that apply)

Text

Phone call

Other

Are you a US Citizen?

What is your ethnic background?

Are you a registered member of an American Indian (Native American) tribe?

What is your marital status?

Please list dates of all marriages, if applicable

Please list dates of all divorces, if applicable

Do you have a partner or spouse?

How did you hear about Family Choice Surrogacy?

Are you working with another agency?

Have you ever been declined by another agency?

Height

Weight (lbs)

lbs

In this section, we will be asking you some additional pre-qualifying questions to see if we’re a good fit for each other!

Do you have implant birth control or have you had implant birth control in the last 6 months?

Are you currently pregnant?

How many C-Sections have you had?

Have you had more than 2 miscarriages?

Are you currently a member of the US Military?

Is your partner/spouse currently a member of the US Military?

Have you ever tested positive for HIV?

Have you previously had chicken pox or received the varicella vaccine?

Have you been vaccinated for MMR (measles, mumps, rubella)?

Have you ever been immunized for Hepatitis B?

Do you currently smoke cigarettes or use tobacco products?

Were you ever a tobacco smoker?

Do you have a history of recreational drug use or alcohol abuse?

Have you taken any anti-depressants, anti-psychotics, or anti-anxiety medications in the past six months?

Have you ever had a psychiatric hospitalization?

Have you ever been diagnosed with any severe psychiatric disorder?

Has any member of your current household ever been diagnosed with mental illness?

Have you had the Covid vaccine?

Have you or anyone in your household been convicted of a felony?

Are you or any member of your household a registered sex offender?

Are you receiving any of the following forms of government financial assistance?

Are you financially stable?

How many total pregnancies have you had? (Include terminations and miscarriages)

Are you actively raising your children?