Secondary Surrogate Application & Profile

Secondary Surrogate Application and Profile

"*" indicates required fields

Your Surrogate Coordinator

Who is your surrogate intake coordinator?*

Your surrogate intake coordinator is the person that sent you an email with a link to this form.

Katy Brown

Shelby Onstot

Not Sure

Basic Information

Name*

First Last

Date of Birth*

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

Are you a United States Citizen or Permanent Resident?*

Yes

Driver's License or Government ID

Max. file size: 25 MB.

Please submit a photo of your government issued ID.

Profile Photos

Please submit 1-4 of the nicest photos you have.

Drop files here or

Max. file size: 25 MB, Max. files: 4.

Do you have medical insurance?*

Yes

Front & Back of Medical Insurance Card

Please submit photos of the front and back of your insurance card.

Drop files here or

Max. file size: 25 MB, Max. files: 2.

What is your ethnic background?*

Caucasian

African American

Asian

Latin American

Other

Rather not say

What is your religious background?*

Christian

Jewish

Muslim

Aetheist

Other

Rather not say

Is it okay to text your phone?*

Yes

Is it okay to leave voice messages?*

Yes

Education, Employment, and Socioeconomics

What is your education level?*

Partial High School

High School or GED

Partial College

Bachelors Degree

Masters Degree

PhD or Doctorate

Are you currently employed?*

Yes

Where are you employed and what do you do?*

What is your annual household income?*

Are you on public assistance?*

Yes

Are you on food stamps?*

Yes

Have you or your family filed for bankruptcy in the last 7 years?*

Yes

Medical & Pregnancy History

Have you ever had difficulty becoming pregnant?*

Yes

How many children have you given birth to?*

Is your menstrual cycle regular?*

Yes

Have your pap smears always been normal?*

Yes

Approximate Date of Last Pap Smear

Have you have any miscarriages or pregnancy losses?*

Yes

Have you had any abortions?*

Yes

Have you have any stillbirth babies?*

Yes

Have you had any C-sections?*

Yes

How many?*

Have you ever been placed on doctor ordered bedrest during you pregnancy*

Yes

Did you have any complications in your pregnancies or deliveries?*

Yes

Please Explain any and all pregnancy/birth complications

Have you ever been diagnosed with endometriosis?*

Yes

Do you or have you ever had diabetes (including gestational diabetes)?*

Yes

Have you ever been diagnosed with preeclampsia?*

Yes

Have you ever been diagnosed with postpartum depression?*

Yes

Have you ever been diagnosed with an eating disorder?*

Yes

Have you ever been seen or treated by a medical professional for a mental health issue?*

Yes

Have you ever been treated for depression?*

Yes

Are you currently on any medications for depression/anxiety?*

Yes

Are you generally healthy?*

Yes

Have you been vaccinated against COVID-19?*

Yes

Covid vaccination card*

Max. file size: 25 MB.

Are you currently breastfeeding?*

Yes

Other than a c-section, have you had any surgeries?*

Yes

Please list all surgeries you have had.*

Have you ever had an illness or injury that required you to be hospitalized*

Yes

Are you currently taking any prescriptions?*

Yes

Please list all medications you are taking?*

Do you have any food allergy?*

Yes

Please list all foods you are allergic to.

Do you have any allergies to medication?*

Yes

Please list all medications you are alergic to*

What is your sexual orientation?*

Heterosexual

Lesbian

Bi-Sexual

Other

Do you have, or have you ever had HIV?*

Yes

Do you have, or have you ever had Hepatitis C*

Yes

Have you ever had a sexually transmitted disease?*

Yes

If sexually active, what method of contraception are you currently using?

write N/A if not sexually active.

Number of sexual partners that you had in the past 3 years

Have you ever received a blood transfusion?*

Yes

Have you ever been in a serious accident?*

Yes

Have you ever been a victim of rape?*

Yes

Have you ever been a victim of physical abuse?*

Yes

Lifestyle Questions

Have you ever been convicted of a crime?

Yes

Please explain the level (misdemeanor, felony) and nature of the crime.*

Are you exposed to any chemicals on a regular basis that might be harmful to a fetus?

Yes

Would you be willing to make the necessary lifestyle changes to avoid all such harmful chemicals for the duration of the surrogacy process?*

Yes

Do you drink alcohol?*

Yes

Do you currently smoke marijuana, tobacco, vape, or illicit drugs?*

Yes

Would you be willing to stop for at a minimum of 6 months before becoming a surrogate and for the duration of your surrogacy journey?**

Yes

Have you ever smoked marijuana, tobacco, vape, or illicit drugs??*

Yes

What did they smoke, how long ago, and for how long?*

Does anyone in your household currently smoke marijuana, tobacco, vape, or illicit drugs?*

Yes

Would they be willing to stop for at a minimum of 6 months before you become a surrogate and for the duration of your surrogacy journey?***

Yes

Has anyone in your household ever smoked marijuana, tobacco, vape, or illicit drugs?*

Yes

What did they smoke, how long ago, and for how long?*

Have you received any tattoos or body piercings in the last 6 months?*

Yes

Do you have pets?*

Yes

Please list all types of pets you have.*

Support System

What is your marital status?*

Married

Single

Divorced

Widowed

Separated

Engaged

Live-in boyfriend/girlfriend

What is your partner's name?*

First Last

Partner's Date of Birth*

What is your partner's phone number?*

How long have you been together?*

Do you live together?*

Yes

What is your partner's level of education:*

Partial High School

High School or GED

Partial College

Bachelors Degree

Masters Degree

PhD or Doctorate

Are the children that you have related to your partner or spouse?*

Yes

Have you ever experienced serious relationship problems or domestic violence in your relationship?*

Yes

Has your partner been convicted of a crime?*

Yes

Please explain the level (ie. misdemeanor/felon) and nature of their crime?*

Is your Partner employed?*

Yes

Where do they work and what do they do?*

Do they work from home?*

Yes

Has your Partner filed for bankruptcy in the last 7 years?*

Yes

Is your partner supportive of your decision to become a surrogate*

Yes

Do other adults (besides a partner) live in your home?*

Yes

What is their relationship to you?*

Is your family supportive of your decision to be a surrogate?*

Yes

Who is your emergency contact?*

Partner

Someone Else

Emergency Contact's Name*

First Last

Emergency Contact's Relation to you*

Emergency Contact's Phone Number*

Surrogacy Comfort Level

During the surrogacy pregnancy, are you comfortable having contact with the intended parents to give them updates regarding the pregnancy?*

Yes

Are you comfortable leaving all future contact with the child that will be born up to the intended parents, with an understanding that it will depend on the relationship you all develop during the pregnancy?*

Yes

Do you feel comfortable having intended mother in the delivery room while you give birth?*

Yes

Do you feel comfortable having intended father in the delivery room while you give birth?*

Yes

Do you feel confident that you will feel 100% comfortable to give the intended parents their child when the child is born?*

Yes

If the parents ask, would you be willing to pump, freeze and ship your breast milk for the child?*

Yes

This field is for validation purposes and should be left unchanged.