Please call us if you have any questions 619.482.9208
First Name:
Last Name:
Age:
What is your height?
What is your exact weight?
Home Phone:
Cell Phone:
E-Mail Address:
Home Address:
City:
State:
Zip:
Are you a United States Citizen?
Yes
No
Have you ever been a Surrogate Mother before?
Yes
No
If so, please briefly describe the details of your experience.
What type of Surrogate do you want to be?
Gestational (IVF)
Traditional (AI)
Either
Undecided
How soon would you like to begin the process?
Immediately
1 month
Unsure
Are you willing & able to travel to LA for up to 10 Dr. visits in a 2 month period of time?
Yes
No
Unsure
If you agree to travel to LA, you will be compensated for all of your travel costs. Do you understand?
Yes
No
Unsure
Are you willing to be a Surrogate for gay Intended Parents?
Yes
No
Unsure
Would you consider becoming a Traditional Surrogate, in which your egg would be used and you'd become pregnant through Artificial Insemination?
Yes
No
What are the ages of your children?
Age
Age
Age
Age
Age
Age
Children:
Have you ever been convicted of a felony?
Yes
No
May we contact you by phone?
Yes
No
Is your schedule flexible to be able to attend doctor appointments?
Yes
No
Do you have any medical or psychological conditions that would interfere with pregnancy?
Yes
No
Have you ever had a c-section delivery and if so, could you obtain copies of your delivery records?
Yes
No
Did you have any complications during any of your pregnancies or deliveries?
Yes
No
If you did have complications, please explain.
Upon receipt of your form and approval, how you would like the application sent to you?
Email
U.S. Mail
Fill in Section:
Why do you want to be a Surrogate?
What form of birth control are you currently using?
Have you ever had any sexually transmitted diseases and If so, what and do you currently have one?
Are you currently taking ANY prescription medication?
Additional infomation we should know?
Additional Questions:
Do you Smoke Cigarettes?
Yes
No
Just Quit
Do you use any illegal drugs or have you recently?
Yes
No
Do you take Anti-depressant Medication?
Yes
No
Please check your current relationship status?:
Married
Single
Relationship
Lesbian
Divorced
If you are married or in a committed relationship is your partner supportive of you becoming a surrogate?
Yes
No
Who will provide you with support during the process, both emotionally and physically?
If something wrong with the baby & the Intended Parents wanted to abort (before 18 weeks) would you agree to do so?
Yes
No
Do you drive, have a valid driver's license & a working vehicle?
Yes
No
Do you have Health Insurance?
Yes
No
If Yes, Name of Insurance Company:
Where did you hear about Surrogate Alternatives?
Online Search:
Magazine Ad:
Professional Referral:
Surrogate/Friend:
Once we receive your completed form we will contact you by phone or email. If you are more comfortable calling and speaking with us, please feel free to do so. We would be happy to explain the process and answer any questions or address any concerns you may have. You may reach us at: (619) 397-0757, please ask for Ann when you call.
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