What is your ethnic bacground:
EMERGENCY CONTACT DETAILS
If not a U.S. Citizen do you have permanent residence?
YOUR FAMILY AND LIVING SITUATION What is your marital status
Have you ever placed a child up for adoption?
If applicaple, (surrogate/spouse/partner) are you current with any child support payments?
If no, please give details of dates and amounts owed
What is your employment status:
Please give details of your employment history for the last 10 years (surrogate and spouse/partner) SURROGATE
SPOUSE/PARTNER
Do you own your own home?
Are you renting from a private landlord?
Are you in subsidized housing (Section 8)?
Are you in receipt or public financial assistance?
Please list everyone that lives in your household:
Are you allergic to any animals?
Please provide details on any health insurance (surrogate/spouse/partner) that you hold:
Have you had any piercings/tattoos in the last 6 months?
Have you ever undergone microblading or semi/permanent make-up?
Have you or your spouse/partner ever been convicted of a crime?
If yes, please specify:
Have you or your spouse/partner ever been arrested?
If yes, please specify:
Do you have any legal cases pending?
If yes, please specify:
Please list your academic history, to include degrees and GPA
What countries have you travelled to in the past two years?
YOUR HEALTH AND MEDICAL HISTORY Have you had a blood transfusion?
If yes, please give the date(s) and reason for the transfusion:
Is your menstrual cycle regular?
Are you currently using birth control?
Do you have any allergies?
If yes, please list your allergies below:
Has your physician prescribed you with an Epi-pen?
Do you take recreational drugs?
Do you smoke tobacco products?
Please describe below your regular dietrary habits:
Are you willing to change your diet if requested by the Intended parents? (The cost would be reimbursed and could include organic food, halal, kosher etc.)
Have you or spous/partner ever been diagnosed with any of the following: (please tick if yes)
Do you have any illness not listed above:
GENERAL Do you have a full driving license?
Do you own/have access to reliable transportation?
Are you willing and able to travel several times during this process? (you will be reimbursed for your costs)
Are you willing to take all medication prescribed by the physician?
You may be required to take medication and/or regular injections for up to 4 months during this process. Do you accept and agree to this?
Do you and your partner (if applicable) agree to complete all necessary testing procedures during this process, to include sexually transmitted disease testing?
Do you and your partner (if applicable) agree to abstain from sexual intercourse/stimulation if so advised by your physician?
Do you and your partner (if applicable) agree to obtain approval from a physician to travel within the USA from 24 week pregnant?
Do you agree not to travel outside of the USA from 24 weeks pregnant until the end of the pregnancy?
YOUR JOURNEY To increase the chances of a positive pregnancy, it is usual industry practice to plant two embryos into your uterus. Bearing this in mind, please answer the following questions.
Would you be willing to carry twins?
Would you be willing to carry triplets?
In some circumstances, a physician might recommend a fetal reduction in multiple embryos in order to protect the health of a surrogate and the baby. A physician may also recommend termination of the pregnancy due to any genetic abnormality. A
termination will never be performed due to the gender of a baby.
Would you be willing to allow Intended Parents the choice to terminate/reduce based on personal choice?
Would you be willing to terminate/reduce on medical advice?
Would you be willing to reduce triplets to twins if medically advised to do so?
Would you be willing to reduce twins to a singleton if medically advised to do so?
In some circumstances an Amniocentesis test is required during the pregnancy to diagnose any chromosomal abnormalities and/or fetal infections. A small amount of the amniotic fluid is removed from the amniotic sac and examined.
Would you be willing to undergo an Amniocentesis test, if medically recommended?
Would you be willing to undergo an Amniocentesis Test if requested by the Intended Parents?
Are you willing to pump breast milk?
Would you be willing to allow Intended Parents to collect cord blood/tissue?
Please tick below the matches you would be willing to accept?
YOUR PREGNANCY HISTORY How many children have you given birth to? Please complete details below
Did you have any complications during any of the above pregnancies? If yes, please list below.
Did you have any of the following conditions during any of your pregnancies? If yes, please complete details below.
Please list, if you had any other issues during a pregnancy:
Are you currently using birth control?
Have you ever been diagnosed with a sexually transmitted disease (STD)?
Have you ever had HIV screening?
Do you have any history of abnormal PAP smears
Have you been immunized for Hepatitis B?
Have you had any surgical or medical procedures?
Are you currently on any medication? If yes, please complete below.
If you answered yes to the above please list your medications in the following format:
ABOUT YOU How would you describe yourself?
What are your interest/hobbies?
Do you speak any other languages?(if yes please specify below)
Have you been a surrogate previously? (if yes please specify below)
If yes to above, please specify:
Why do you want to be a surrogate?
Who will be supporting you through your journey?
If you already have children, who will support you if any medical issues arise or you are recommended to bed rest?
Is there anything that you would like to ask us?
WHAT HAPPENS NEXT? Once you have completed this form (please check you have answered the ALL questions), upload an up-to-date photograph of yourself and email to nappy.endings@yahoo.com
AND FINALLY....How did you hear about us? :)
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