Surrogate Intake
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Email *
First name *
Last name *
Maiden/Former/Other name *
Phone number *
Date of Birth *
Country *
Street Address *
City *
State *
Zip Code *
County *
Are you a US citizen or green card holder? *
Relationship Status *
Length of relationship/marriage
Height *
Weight *
Race/Ethnicity *
Preferred pronouns
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Have you been a surrogate or egg donor before? *
Are you, your partner/spouse, or any members of your family registered members of a Native American tribe? *
Total number of pregnancies *
Total number of pregnancies resulting in live birth *
Do you have physical custody of your own child/ren? If no, please provide details. *
Please list dates of all deliveries (month and year) of all the children you have given birth to. *
How many weeks and days were each of your children delivered at? *
What did each of your children weigh at delivery? *
Please list any reproductive events (miscarriages, abortions, premature delivery or stillbirths) or diseases that you have experienced. Please indicate the date(s), complications, outcome, circumstances, etc. *
Do any of the children you gave birth to have any health problems? If so, please specify. *
Number of cesarian sections *
Any pregnancy or delivery complications? *
Do you want to have any more children? If so, when? *
Did you need any medical assistance to conceive your children? If yes, please explain: *
Are you currently breastfeeding? If so, when do you plan to wean? *
Are you currently using birth control and if so, what type? *
What is your occupation? *
Are you or any of your household family members on any form of government assistance (WIC, Medicaid, food stamps, etc.)? If so, please give details as to what kind of assistance and who receives the benefits. *
Do you have health insurance? If so, what is the insurance company name? *
Is your health insurance or any health insurance for your family members part of a state or federally funded program such as Medicaid? If yes, please give details on the name of the program and who receives the benefits. *
Did you graduate high school / receive your GED? *
Secondary Education and Years Attended / Degrees Achieved *
Do you have a spouse/partner?
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