| First Name |
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| Last Initial |
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| What state do you live in? |
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| Your Surrogate Fee |
If you do not have a set fee, please leave zero "0".
Otherwise enter numbers only. DO NOT put $ sign in front of your figure.
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| Telephone |
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| Email |
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| Upload Photo | |
| Date of Birth? |
Please use MM/DD/YYYY format for date.
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| US Citizen? |
Yes |
No
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| Marital Status? |
Single |
Engaged |
Married |
Separated |
Divorced |
Widowed
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Insurance Information
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| Health Insurance? |
Yes |
No
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| Own Car? |
Yes |
No
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| Auto Insurance? |
Yes |
No
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Surrogate History
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| Previous Surrogate? |
Yes |
No
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| Occupation: |
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| IVF or AI or Both: |
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| Blood Type? |
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| Body Build |
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| Height |
feet inches |
| Weight (lbs) |
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| Regular Menstral Cycle? |
Yes |
No
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| Menstral Cycle Length: |
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| Birth Control Method: |
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| Education |
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| Clubs & Organizations: |
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| Talents: |
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Health Information
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| General Health: |
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| Medical Problems: |
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| Allergies: |
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| What prescribed medications are you currently taking? |
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| Have you ever had any serious injuries? |
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| Broken Bones? |
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| Serious Illness? |
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| Operations: Procedures Year & State |
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| Are you under a physicans care? |
Yes |
No
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| If Yes, please explain: |
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| Are you currently taking any medication? How often and purpose: |
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| Alcohol Use Yes/No? |
Yes |
No
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| If Yes, how often and quanity? |
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| Do you smoke? |
Yes |
No
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| Do you use illegal drugs? |
Yes |
No
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| Have you ever been arrested and/or convicted of a crime/felony? |
Yes |
No
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| Have you had any therapy with a psychiatrist or any other mental health professional? |
Yes |
No
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| If Yes, please explain: |
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| Have you had any psychiatric hospitalizations? |
Yes |
No
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| If Yes, please explain: |
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Pregnancy History
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| Number Pregnancies: |
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| Live Births: |
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| Miscarriages: |
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| Abortions: |
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| Pregnancy Problems |
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Education
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| High School Name & Level Completed / GPA: |
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| College Name & Level Completed / GPA: |
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| Have yo met your eductional goals? |
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| College Major: |
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| In what subjects did you recive the highest grades? |
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| Do you have any learning disabilities? |
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General Questions
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| What is your favorite
Movie
?
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| What is your favorite
TV Show
?
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| What is your favorite
Color
?
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| What is your favorite
Book/Author
?
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| What is your favorite
Place
?
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| What is your favorite
Hobby
?
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| What is your favorite
Food
?
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| What is your favorite
Music
?
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| Why do you want to become a surrogate? |
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What qualities do you consider to be most important in choosing to work with the Intended Parents?
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Do you want the Intended Parents to attend obstetrical appointments with you?
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If the Intended Parents request an abortion, will you agree to it?
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If the Intended Parents request a reduction, will you agree to it?
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Will you be willing to carry Multiples (twins, triples, etc)?
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What type of relationship would you like with your Intended Parents?
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Would you like the Intended Parents present during the birth?
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What would you like the Intended Parents to tell their children about you?
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If the Child requests to meet you, how will you feel?
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What reassurance can yo give the Intended Parents that you will not change our mind about relinquishting the Baby/Babies?
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| Can you travel? |
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