Start a Surrogate Application If you need to log out before completing the application remember to save in step 8. PERSONAL INFORMATIONName Username* First Name* Last Name* E-mail* Password* Repeat Password* Address* City* State* Postal Code Country* United StatesAlbaniaAlgeriaAndorraAngolaAntiguaBarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBoliviaBosnia and HerzegowinaBotswanaBrazilBruneiBulgariaCambodiaCameroonCanadaCosta RicaCote d-IvoireCroatiaCyprusCzech RepublicDenmarkDominicaDominican RepublicEcuadorEgyptEl SalvadorEstoniaEthiopiaFijiFinlandFranceGeorgiaGermanyGhanaGibraltarGreeceGrenadaGuadeloupeGuamGuatemalaGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKorea-North KoreaKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritiusMexicoMicronesiaFederated States of MoldovaMonacoMongoliaMoroccoMozambiqueNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNorwayOmanPakistanPalauPanamaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaSaint KittsSaint LuciaSaint Vincent and the GrenadinesSamoaSaudi ArabiaSenegalSeychellesSingaporeSlovakiaSloveniaSouth AfricaSpainSri LankaSurinameSwazilandSwedenSwitzerlandRepublic TaiwanChinaTajikistanTanzaniaThailandTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab Emirates United KingdomUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaVietnamWallis and Futuna Islands WesternSaharaYemenZambiaZimbabwe Cell Phone* Your Age Today* Birth Date* Emergency Contact Name and Relationship Emergency Contact Cell Number Where did you learn about Fertility Heaven?* Have you been a surrogate before? YesNo FIRST TIME surrogates $45,000 REPEAT surrogates $55,000 West Coast Surrogates: $65,000 and up*$45000$50000$55000$60000$65000SURROGATE PROFILE Height5 feet5 feet 15 feet 25 feet 35 feet 45 feet 55 feet 65 feet 75 feet 85 feet 95 feet 105 feet 116 feet Weight RaceAsianAfrican AmericanCaucasianEast AsianEast IndianJewishLatinaNative American Religion or Spiritual Have you been a surrogate before?YesNo 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* PREGNANCY HISTORY×The maximum number of fields has been reached.×+ Child's Date of Birth Your Child's Name Gestation Week at Birth Weight at birth Child's GenderMaleFemale Vaginal, C-section, Abortion, Miscarriage, Stillborn? Multiple (twin)?YesNo×+ Child's Date of Birth Your Child's Name Gestation Week at Birth Weight at birth Child's GenderMaleFemale Vaginal, C-section, Abortion, Miscarriage, Stillborn? Multiple (twin)?YesNoSCREENING QUESTIONS Do you have a reliable vehicle and valid license?YesNo 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)YesNo Do you smoke cigarettes? Does anyone in the household smoke?*YesNo Can you support your family without surrogacy income?YesNo 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?YesNo Is your partner employed?YesNoN/A Job title and description of your partner's job Do you have Life Insurance?YesNo Do you have Health Insurance?YesNo Is your insurance through your employer?YesNo Who is your Health Insurance provider? Are you on antidepressants?YesNo Do you collect any government aid to support your family? Please describe the State or Federal-aid you receive? Are you breastfeeding?*YesNo Did any of your children require any medical attention at birth?YesNo Describe the medical attention your children needed at birth Have you given any children up for adoption?YesNo Why did you give a child up for adoption? Do all of your biological children live with you full time?YesNo Does your partner support your decision to be a surrogate?YesNoDon't have a partner 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?* YesNo 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?YesNo How often do you drink alcoholic beverages? Have you ever drank alcoholic beverages while pregnant?YesNo Does anyone else in your household drink?YesNo Describe how much they drink, where and how often Have you ever taken any illegal drugs?YesNo List all prescription medicine you take now and have in the past Include the usage and dosage Is your partner in good health?YesNo Describe any health issues your partner has Have you ever had to see a therapist for emotional issues?YesNo 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?YesNo 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?YesNo Please list your hospitalization, reasons, and outcome Did you have morning sickness?YesNo 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?YesNo Are you willing to take shots as part of the fertility process?YesNo Do you suffer or have been treated for any of the below medical conditions?AbortionAbnormal cells-cervixADD/ADHDAnxietyArthritisAsthmaBi-polarCancerCerclageConvulsionsDepressionDiabetesEpilepsyGestational DiabetesHeart DiseaseHerpesHigh blood pressureHigh or Low ThyroidHPVKidney ProblemsLiver DiseaseMental IllnessMigrainesMiscarriageOvarian cystsPlacenta abruptionPlacenta PreviaPost-partum DepressionPre-eclampsiaPreterm labor or deliverySkin DisordersShorting of the cervixTay Sachs TumorsUterine CystsUlcersUterine fibroidsOther If yes, please indicate and describe Have you received the series of vaccinations for Hepatitis B?YesNo Do you have the COVID19 Vaccine?*YesNo Are you familiar with the fertility drugs and injections surrogates must take before and during a pregnancy?YesNo Are you open to carrying twins?YesNo Are you comfortable carrying triplets?YesNo 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?YesNo 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?YesNo 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?YesNo Are you willing to allow your IPs the decision for you to have a selective reduction performed with no medical reason?YesNo Are you willing to allow your IPs the difficult decision to terminate the surrogacy pregnancy between 13 and 20 weeks of gestation?YesNo Are you willing to terminate a surrogate pregnancy if your own life is at risk as this would automatically turn into an emergency?YesNo Are you willing to have an amnio if you're physician or intended parents recommended it?YesNo Are you open to 2 embryos being transferred with a small chance of twins resulting?YesNoSURROGATE 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? SURROGATE PHOTOS (please click update after uploading 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.*Upload A recent photo that includes your entire body:Upload A picture that includes everyone in your household:Upload A favorite picture of yourself:Upload A picture with your partner:Upload Any other picture you want:Upload PhotoUpload PhotoUpload PhotoUpload PhotoUpload Surrogate VideoUpload 60 second video (filetype mp4 or mov)Do you want a copy of this form sent to you by email?
