Surrogate Application

 

First Name:
Last Name:
Email Address:
Verify Email Address:
Date of birth:
Age:
Street Address:
City:
State:
Zip Code:
What is the closest major city to where you live?
Best Contact Phone Number:
Is it okay to leave a message?
Second Contact Phone Number:
Is it okay to leave a message?
Ethnicity:
Religious background:
Height:
' "
Weight:
BMI:
Marital status:
Spouse/Partner Full Name:
Are you currently employed?
Are you currently enlisted in the Military?
Is your spouse currently enlisted in the Military?
Do you have your high school diploma or GED?
Please list in detail your level of education beyond high school:
Do you have any medical problems? If so, please explain in detail:
Have you ever had any surgeries? If so please provide details for each surgery:
Have you given birth before?
Number of pregnancies (please include miscarriages and abortions):
Number of children:
Please list the age(s) of your child(ren):
Have you delivered a child vaginally?
Have you had a cesarean (c-section)?
Please provide details:
Please specify if you have had any of the following complications throughout any of your past pregnancies:
Placenta Previa
Please provide details:
Toxemia
Please provide details:
Pre-Eclampsia
Please provide details:
Anemia
Please provide details:
Pregnancy-induced hypertension
Please provide details:
Gestational Diabetes
Please provide details:
Have you been a surrogate mother before?
Do you smoke or use tobacco?
Have you smoked in the past 12 months?
Are you willing to take a nicotine screening test?
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:
Have you used any illegal drugs in the past 12 months?
Are you willing to take a drug test?
Have you ever been a member of a drug or alcohol treatment program?
Are you currently taking any medications? If yes, please list each medication and the reason the medication has been prescribed to you.
Number of sexual partners in your lifetime:
Number of sexual partners in the past 12 months:
Number of sexual partners in the past 30 days:
Have your or your partner tested positive for Chlamydia in the past 12 months?
Have your or your partner tested positive for Gonorrhea in the past 12 months?
Have your or your partner tested positive for Syphilis in the past 12 months?
Have you or your partner tested positive for HIV/AIDS?
Have you ever been diagnosed with Genital Herpes?
Have you received a tattoo in the past 12 months?
Have you received a piercing in the past 12 months?
Do you currently have health insurance?
When was your last pap smear and what was the result (if abnormal what was your doctors suggested course of action?)
Are you currently receiving any type of government assistance?
Have you ever been arrested?
Have you ever received a DUI or DWI?
Have you or your partner ever been convicted of a felony?
Have you ever been diagnosed as clinically depressed?
Have you ever been diagnosed with post-partum depression?
Have you ever been prescribed anti-depressants?
Have you ever been prescribed anti-anxiety medication?
Have you ever attempted suicide?
Have you ever had a child removed from your home?
Have you ever lost custody of a child?
Have you ever been a victim of domestic violence?
If your application is approved are you willing to have your full medical records released to Family Creations, LLC.?
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?
Are you willing to undergo a home visit conducted by a Family Creations staff member?
How did you hear about us?
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.
Click this check box if you agree