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Personal Information

Username *
First Name *
Last Name *
Password *
Confirm Password *
Email Address *
Address *
City *
State *
Postal Code
Country *
Cell Phone *
Your Age Today *
Birth Date
Emergency Contact Name and Relationship
Emergency Contact Cell Number
Where Did You Learn About Fertility Heaven? *
FIRST TIME surrogates $50,000 REPEAT surrogates $65,000 West Coast Surrogates: $65,000 and up
Please Fill all The Required Fields to Proceed.

Surrogate Profile

Height
Weight
Race
Religion or Spiritual
Have You Been a Surrogate Before?
Total Number of Births?
Were Your Children Born Healthy? *
Please describe your pregnancies, were they healthy and happy? *
Have you had any pregnancy or birth complications? *
Have you ever been placed on strict bed rest by a physician? *
Please list medications used during pregnancy and delivery *
How many biological children do you have? *
Stepchildren *
Please Fill all The Required Fields to Proceed.
Your Child's Name
Child's Date of Birth
Gestation Week at Birth
Weight at birth
Child's Gender
Vaginal, C-section, Abortion, Miscarriage, Stillborn?
Multiple (twin)?
Do you Have a 2nd Child?
Your Child's Name
Child's Date of Birth
Gestation Week at Birth
Weight at birth
Child's Gender
Vaginal, C-section, Abortion, Miscarriage, Stillborn?
Multiple (twin)?
Do you Have a 3rd Child?
Your Child's Name
Child's Date of Birth
Gestation Week at Birth
Weight at birth
Child's Gender
Vaginal, C-section, Abortion, Miscarriage, Stillborn?
Multiple (twin)?
Do you Have a 4th Child?
Your Child's Name
Child's Date of Birth
Gestation Week at Birth
Weight at birth
Child's Gender
Vaginal, C-section, Abortion, Miscarriage, Stillborn?
Multiple (twin)?
Do you Have a 5th Child?
Your Child's Name
Child's Date of Birth
Gestation Week at Birth
Weight at birth
Child's Gender
Vaginal, C-section, Abortion, Miscarriage, Stillborn?
Multiple (twin)?
Please Fill all The Required Fields to Proceed.

Pregnancy History

Do you have a reliable vehicle and valid license?
You will be required to submit a current pap smear, a clearance letter from your ob/gyn, and the prenatal and delivery records of your children. Are you able to comply with this requirement? (We will assist you in obtaining these records)
Do you smoke cigarettes? Does anyone in the household smoke? *
Can you support your family without surrogacy income?
Number of years together with partner
Partner's name
Your Job Title and Description of Job
Do you or your partner have a criminal record? Have you ever been arrested?
Is your partner employed?
Job title and description of your partner's job
Do you have Life Insurance?
Do you have Health Insurance?
Is your insurance through your employer?
Who is your Health Insurance provider?
Are you on antidepressants?
Do you collect any government aid to support your family? Please describe the State or Federal-aid you receive?
Are you breastfeeding?
Did any of your children require any medical attention at birth?
Describe the medical attention your children needed at birth
Have you given any children up for adoption?
Why did you give a child up for adoption?
Please Fill all The Required Fields to Proceed.

Screening Questions

Do all of your biological children live with you full time?
Does your partner support your decision to be a surrogate?
List all people below you live within your household
List any family members that live near you, such as siblings, parents, grandparents
What family, friends or community support will you have during your pregnancy?
Are your children in daycare?
Name of OB physician who took care of your prenatal care during your last most recent pregnancy
Do you have any medical problems we should be aware of?
When was your last PAP Smear month/year?
Have you ever had an abnormal pap smear? If yes, please describe the course of action physician recommended
Have you had plastic surgery?
If yes please list procedure(s)
Is there anything about your health or life circumstances that concerns you and you think might impact your ability to be a surrogate, have a healthy pregnancy and deliver a healthy baby for intended parents?
Describe what your health or life concerns are that you think might impact your pregnancy or delivery
Do you drink alcoholic beverages?
How often do you drink alcoholic beverages?
Have you ever drank alcoholic beverages while pregnant?
Does anyone else in your household drink?
Describe how much they drink, where and how often
Have you ever taken any illegal drugs?
List all prescription medicine you take now and have in the past Include the usage and dosage
Please Fill all The Required Fields to Proceed.
Is your partner in good health?
Describe any health issues your partner has
Have you ever had to see a therapist for emotional issues?
Describe the reason for seeing a therapist and how many times you saw them and during what period of time
Do you have any allergies?
Please list the allergies you have experienced, what time in your life you had them, if you took any medicine for them and if you are still experiencing them?
Have you ever been hospitalized?
Please list your hospitalization, reasons, and outcome
Did you have morning sickness?
Please describe your overall health and diet
Are you willing to eat organic foods if future intended parents requested it? Assuming they would cover the extra costs?
Are you willing to take shots as part of the fertility process?
Do you suffer or have been treated for any of the below medical conditions?
If yes, please indicate and describe
Have you received the series of vaccinations for Hepatitis B?
Do you have the COVID19 Vaccine? *
Are you familiar with the fertility drugs and injections surrogates must take before and during a pregnancy?
Are you open to carrying twins?
Are you comfortable carrying triplets?
Please list the type of couples you are open to working with. (heterosexual married couples, unmarried couples, same-sex couples, single mother, single father, gay single parent). Please also list if you are open to international couples Surrogate have the final say with whom they move forward with to ensure you are matched comfortably.
Are you willing to allow your IPs the decision to have selective reduction if the RARE event of embryos splitting into identical twins, resulting in triplet pregnancy, it would be medically recommended to reduce the twin sac?
Are you willing to allow your IPs the decision for you to have a selective reduction performed if twins occurred? If medically recommended by a physician?
Are you willing to allow your IPs the decision for you to have a selective reduction performed if triplets occurred? If medically recommended by a physician?
Are you willing to allow your IPs the decision for you to have a selective reduction performed with no medical reason?
Are you willing to allow your IPs the difficult decision to terminate the surrogacy pregnancy between 13 and 20 weeks of gestation?
Are you willing to terminate a surrogate pregnancy if your own life is at risk as this would automatically turn into an emergency?
Are you willing to have an amnio if you're physician or intended parents recommended it?
Are you open to carrying twins if the embryo splits?
Please Fill all The Required Fields to Proceed.

SURROGATE PERSONALITY

Why have you decided to become a surrogate?
What kind of relationship would you like to have with the intended parents of this surrogacy?
Is there anything you would like to tell intended parents about yourself that demonstrates you are a caring and responsible person?
What do you do for fun?
What is your family like?
What are your values as a person?
Please Fill all The Required Fields to Proceed.

Surrogate Photos

A great close-up of your face with at least one child next to you: This will likely be your main profile photo we use. *
Maximum file size: 30 MB
A recent photo that includes your entire body: *
Maximum file size: 30 MB
A picture that includes everyone in your household: *
Maximum file size: 30 MB
A picture with your partner:
Maximum file size: 30 MB
Any other picture you want:
Maximum file size: 30 MB
Please Fill all The Required Fields to Proceed.
Photo 6
Maximum file size: 30 MB
Photo 7
Maximum file size: 30 MB
Photo 8
Maximum file size: 30 MB
Photo 9
Maximum file size: 30 MB
Photo 10
Maximum file size: 30 MB
A small Video
Maximum file size: 200 MB

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