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The form will take approximately 10-15 minutes to fill out. Please answer truthfully and if you get stuck or need help, just use the chat in the right corner and someone will be able to assist you.

First Name

Last Name

Address

Date of Birth

Cell Phone

Home Phone

Work Phone

Email Address

EMERGENCY CONTACT DETAILS

Do you practice religion

Yes

What religion do your practice

What citizenship do you hold

If not a U.S. Citizen do you have permanent residence?

Yes

YOUR FAMILY AND LIVING SITUATION

How many biological children do you have?

Have you ever placed a child up for adoption?

Yes

If applicaple, (surrogate/spouse/partner) are you current with any child support payments?

Yes

If no, please give details of dates and amounts owed

What is your employment status:

Employed Full-time

Employed Part-time

Actively looking for employment

Unemployed

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?

Yes

Are you renting from a private landlord?

Yes

Are you in subsidized housing (Section 8)?

Yes

Are you in receipt or public financial assistance?

Yes

Please list everyone that lives in your household:

Do you have any pets?

Yes

If yes, please specify:

Are you allergic to any animals?

Yes

If yes, please specify:

Please provide details on any health insurance (surrogate/spouse/partner) that you hold:

Have you had any piercings/tattoos in the last 6 months?

Yes

Have you ever undergone microblading or semi/permanent make-up?

Yes

Have you or your spouse/partner ever been convicted of a crime?

Yes

If yes, please specify:

Have you or your spouse/partner ever been arrested?

Yes

If yes, please specify:

Do you have any legal cases pending?

Yes

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

What is your height?

What is your weight?

What is your BMI? (To calculate: it i your weight in kilograms divided by the square of you height in metres)

What is your bloodtype?

Have you had a blood transfusion?

Yes

If yes, please give the date(s) and reason for the transfusion:

Is your menstrual cycle regular?

Yes

On average, how long does your cycle last?

Are you currently using birth control?

Yes

Please specify(e.g. pill, condoms, coil etc.

Do you have any allergies?

Yes

If yes, please list your allergies below:

Has your physician prescribed you with an Epi-pen?

Yes

Do you drink alcohol?

Yes

How many units of alcohol per week?

Do you take recreational drugs?

Yes

If yes, please state:

Do you smoke tobacco products?

Yes

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.)

Yes

Do you have any illness not listed above:

GENERAL

Do you have a full driving license?

Yes

Do you own/have access to reliable transportation?

Yes

Are you willing and able to travel several times during this process? (you will be reimbursed for your costs)

Yes

Are you willing to take all medication prescribed by the physician?

Yes

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?

Yes

Do you and your partner (if applicable) agree to complete all necessary testing procedures during this process, to include sexually transmitted disease testing?

Yes

Do you and your partner (if applicable) agree to abstain from sexual intercourse/stimulation if so advised by your physician?

Yes

Do you and your partner (if applicable) agree to obtain approval from a physician to travel within the USA from 24 week pregnant?

Yes

Do you agree not to travel outside of the USA from 24 weeks pregnant until the end of the pregnancy?

Yes

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?

Yes

Would you be willing to carry triplets?

Yes

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?

Yes

Would you be willing to terminate/reduce on medical advice?

Yes

Would you be willing to reduce triplets to twins if medically advised to do so?

Yes

Would you be willing to reduce twins to a singleton if medically advised to do so?

Yes

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?

Yes

Would you be willing to undergo an Amniocentesis Test if requested by the Intended Parents?

Yes

Are you willing to pump breast milk?

Yes

Would you be willing to allow Intended Parents to collect cord blood/tissue?

Yes

Please tick below the matches you would be willing to accept?

Intended Parents living in the USA

Intended Parents living internationally

Intended Parents with children

Intended Parents of the same sex

Intended Parents that are bi-racial

Intended Parents that are single

Intended Parents that are HIV positive

Intended Parents that are carriers of Hepatitis B

What amount are you requesting for your base fee?

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.

Please list, if you had any other issues during a pregnancy:

Are you currently using birth control?

Yes

Have you ever been diagnosed with a sexually transmitted disease (STD)?

Yes

Have you ever had HIV screening?

Yes

Do you have any history of abnormal PAP smears

Yes

Have you been immunized for Hepatitis B?

Yes

Have you had any surgical or medical procedures?

Yes

Are you currently on any medication? If yes, please complete below.

Yes

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?

What is the main language spoken in your household?

Do you speak any other languages?(if yes please specify below)

Yes

If you answered yes to the above, please list the languages below (separate with a comma)

Have you been a surrogate previously? (if yes please specify below)

Yes

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

Thanks for submitting!

Apply Here

EMERGENCY CONTACT DETAILS

YOUR FAMILY AND LIVING SITUATION

Please give details of your employment history for the last 10 years (surrogate and spouse/partner)

YOUR HEALTH AND MEDICAL HISTORY

GENERAL

YOUR JOURNEY

YOUR PREGNANCY HISTORY

ABOUT YOU

WHAT HAPPENS NEXT?

UK Office