Surrogate Intake Form

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HELLO! We are sooo excited to meet you! Someone on our intake team will be in contact with you within one business day.

Full Name (First, Middle, Last) *

Full Home Address (including city, state, zip) *

Email *

Phone Number *

Date of Birth *

YYYY

How old are you? *

Height *

Weight *

Why would you like to be a surrogate? *

Have you been a surrogate before? *

Yes

How did you hear about us? (friend, Facebook, google, referral, radio etc) Please specify name of referral, group, or ad you heard/saw *

Are you on government assistance? *

Do you currently have health insurance? *

Current job title & duties: *

What is your relationship status? *

Legally Married

Single

Separated, still legally married

Divorced

Long Term Relationship with Partner

Spouse/Partner's Name

Spouse/Partner's DOB

YYYY

Spouse/Partner Email

How many times have you been pregnant? *

Have you had any miscarriages or abortions? If so, please share at how many weeks *

Pregnancy #1- Name, birthday, gestation, any complications? Vaginal or C Section? OB/Clinic and delivering hospital name. *

Pregnancy #2- Name, birthday, gestation, any complications? Vaginal or C Section? Keeper or surrogacy? OB/Clinic and delivering hospital name. Please Include IVF clinic information if applicable.
*

Pregnancy #3- Name, birthday, gestation, any complications? Vaginal or C Section? Keeper or surrogacy? OB/Clinic and delivering hospital name. Please Include IVF clinic information if applicable.
*

Pregnancy #4- Name, birthday, gestation, any complications? Vaginal or C Section? Keeper or surrogacy? OB/Clinic and delivering hospital name. Please Include IVF clinic information if applicable.
*

Pregnancy #5- Name, birthday, gestation, any complications? Vaginal or C Section? Keeper or surrogacy? OB/Clinic and delivering hospital name.Please Include IVF clinic information if applicable. *

Pregnancy #6- Name, birthday, gestation, any complications? Vaginal or C Section? Keeper or surrogacy? OB/Clinic and delivering hospital name. Please Include IVF clinic information if applicable.
*

Pregnancy #7- Name, birthday, gestation, any complications? Vaginal or C Section? Keeper or surrogacy? OB/Clinic and delivering hospital name. Please Include IVF clinic information if applicable. *

Pregnancy #8- Name, birthday, gestation, any complications? Vaginal or C Section? Keeper or surrogacy? OB/Clinic and delivering hospital name. Please Include IVF clinic information if applicable. *

When was your last pap smear? *

Have you ever had an abnormal pap pathology result? *

Yes

Unsure

Have you EVER had an STI? Please specify what, when, and if it has resolved or if you have recurring care for it. (This includes chlamydia, herpes type 2, history of HPV, etc)

List any current health conditions: *

List any surgeries or procedures you've had: *

List any current medications you are taking, including birth control: *

Are you currently breastfeeding or pumping? *

Yes

Are you vaccinated against Covid 19? *

Yes

Yes with booster(s)

No and don't want to get vaccinated

No and open to getting vaccinated if clinic or IPs desire

Would you be willing to visit your most recent provider to have a clearance letter for surrogacy filled out and returned to our agency? *

Yes

Do you have the time and energy to fulfill the entire journey of surrogacy? *

Yes

Do you have a support system to help you through this journey? *

Yes

Tell us one cool fact about you that makes you stand out! :) *

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