Surrogate Application

 

First Name: *
You must provide your first name.
Last Name: *
You must provide your lastname.
Email Address: *
You must provide email address Email address must be valid
Verify Email Address: *
You must verify your email address This verification e-mail address does not match the field above.
Date of birth: *
You must provide date of birth in correct format: month - day - year. You must provide a valid year
Age: *
Street Address: *
You must provide street address
City: *
You must provide city
State:
Zip Code: *
You must provide zip code
What is the closest major city to where you live? *
You must provide the closest major city to where you live
Best Contact Phone Number: *
You must provide best contact phone number.
Is it okay to leave a message?
You must provide this information
Second Contact Phone Number: *
You must provide second contact phone number.
Is it okay to leave a message?
You must provide this information
Ethnicity: *
You must provide your ethnicity.
Religious background: *
You must provide your Religious background.
Height: *
' "
You must provide your height. You must provide a valid height.
Weight: *
You must provide your weight.
BMI: *
Marital status:
Spouse/Partner Full Name:
Are you currently employed? *
You must provide this information
If yes, what is your occupation? *
You must provide this information.
Are you currently enlisted in the Military? *
You must state whether you are currently enlisted in the Military.
Is your spouse currently enlisted in the Military?
Do you have your high school diploma or GED? *
You must provide this information
Please list in detail your level of education beyond high school: *
You must provide this information
Do you have any medical problems? If so, please explain in detail: *
You must provide this information
Have you ever had any surgeries? If so please provide details for each surgery: *
You must provide this information
Have you given birth before? *
You must provide this information
Number of pregnancies (please include miscarriages and abortions): *
You must provide number of pregnancies Please enter a valid number
Number of children: *
You must provide number of children Please enter a valid number
Please list the age(s) of your child(ren): *
You must provide this information
Have you delivered a child vaginally? *
You must provide this information
Have you had a cesarean (c-section)? *
You must provide this information
Please provide details: *
You must provide this information
Please specify if you have had any of the following complications throughout any of your past pregnancies:
Placenta Previa *
You must provide this information
Please provide details: *
You must provide this information
Toxemia *
You must provide this information
Please provide details: *
You must provide this information
Pre-Eclampsia *
You must provide this information
Please provide details: *
You must provide this information
Anemia *
You must provide this information
Please provide details: *
You must provide this information
Pregnancy-induced hypertension *
You must provide this information
Please provide details: *
You must provide this information
Gestational Diabetes *
You must provide this information
Please provide details: *
You must provide this information
Have you been a surrogate mother before? *
You must provide this information
If so, how many times: *
You must provide this information
Do you smoke or use tobacco? *
You must provide this information
Have you smoked in the past 12 months? *
You must provide this information
Are you willing to take a nicotine screening test? *
You must provide this information
Have you ever used a mind altering drug such as marijuana, cocaine, heroin, ecstasy, LSD or methamphetamines? If so, please explain which drug, frequency of use, and last date used: *
You must provide this information
Have you used any illegal drugs in the past 12 months? *
You must provide this information
Are you willing to take a drug test? *
You must provide this information
Have you ever been a member of a drug or alcohol treatment program? *
You must provide this information
Are you currently taking any medications? If yes, please list each medication and the reason the medication has been prescribed to you. *
You must provide this information
Number of sexual partners in your lifetime: *
You must provide this information Please enter a valid number
Number of sexual partners in the past 12 months: *
You must provide this information Please enter a valid number
Number of sexual partners in the past 30 days: *
You must provide this information Please enter a valid number
Have your or your partner tested positive for Chlamydia in the past 12 months? *
You must provide this information
Have your or your partner tested positive for Gonorrhea in the past 12 months? *
You must provide this information
Have your or your partner tested positive for Syphilis in the past 12 months? *
You must provide this information
Have you or your partner tested positive for HIV/AIDS? *
You must provide this information
Have you ever been diagnosed with Genital Herpes? *
You must provide this information
Have you received a tattoo in the past 12 months? *
You must provide this information
Have you received a piercing in the past 12 months? *
You must provide this information
Do you currently have health insurance? *
You must provide this information
If so, who is your insurance provider (i.e. Aetna, BlueCross) and what type of coverage do you have (i.e. HMO, PPO)? *
You must provide this information
When was your last pap smear and what was the result (if abnormal what was your doctors suggested course of action?) *
You must provide this information
Are you currently receiving any type of government assistance? *
You must provide this information
Have you ever been arrested? *
You must provide this information
Have you ever received a DUI or DWI? *
You must provide this information
Have you or your partner ever been convicted of a felony? *
You must provide this information
Have you ever been diagnosed as clinically depressed? *
You must provide this information
Have you ever been diagnosed with post-partum depression? *
You must provide this information
Have you ever been prescribed anti-depressants? *
You must provide this information
Have you ever been prescribed anti-anxiety medication? *
You must provide this information
Have you ever attempted suicide? *
You must provide this information
Have you ever had a child removed from your home? *
You must provide this information
Have you ever lost custody of a child? *
You must provide this information
Have you ever been a victim of domestic violence? *
You must provide this information
If your application is approved are you willing to have your full medical records released to Family Creations, LLC.? *
You must provide this information
If your application is approved are you (and your spouse if applicable) willing to have a full background check conducted and released to Family Creations? *
You must provide this information
Are you willing to undergo a home visit conducted by a Family Creations staff member? *
You must provide this information
How did you hear about us? *
You must provide this information
I agree that I represent that all written representations and information provided and/or to be provided to Family Creations, LLC, and any professional, psychologist, physician, physician's assistant, nurse, attorney, or designee of Family Creations, are true, correct and complete.
You must agree with following disclaimer if you wish to apply.
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