GC Intake Form
Thank you for your interest in being a surrogate, it is such a rewarding experience for most! Please fill out the following intake information to help us determine your eligibility per the guidelines of the many fertility clinics our Intended Parents work with. A more comprehensive questionnaire and pictures for your profile will be requested at a later time when you are closer to the matching process to ensure clear understanding of your matching criteria.
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Full Name *
Street Address *
City, State, Zip *
Email address *
Phone number *
Date of Birth *
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Height *
Weight *
Are you currently breastfeeding (nursing or pumping)? *
If you are breastfeeding and/or pumping, have you had a period yet? *
If you have a criminal record other than driving offenses, please describe dates, charges and circumstances.  *
What is your occupation? *
Are you currently on any form of Government assistance? (i.e. welfare, food stamps, government funded housing, adults on Medicaid) *
Will your schedule allow you to attend doctor's appointments? During the month before and after embryo transfer, plan on weekly appointments.  *
Do you have appropriate supports to help with your children in case of pregnancy complications? *
Current marital status: *
Is your family complete? *
Did someone refer you to United Surrogacy? If so, who? *
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