Surrogate Application
Please fill out the following application to receive more information about becoming a Surrogate with Midwest Surrogacy LLC
First Name *
Last Name *
Age *
Email *
Street Address *
City *
State/Region *
Postal Code/Zip Code *
Phone Number *
Height
Weight
Sexual Orientation
Marital Status
Check any/all that apply
Ages of Children
Do you have any adopted children? If so, ages?
Are you fostering any children? If so, ages?
Citizenship
Other than English, what other languages do you or your family speak and write?
Check any/all that apply
Name of spouse or partner
How does your partner feel about your interest in surrogacy?
Is he/she supportive and willing to undergo any required testing?
Check any/all that apply
What medical insurance company do you use?
Are there any surrogacy exclusions?
Check any/all that apply
When are you willing/able to start?
Are you willing to work with: (Check any/all that apply)
How many pregnancies have you had?
How many c-sections have you had?
Have you had any pregnancy complications? (i.e. gestational diabetes, pre-term labor, preeclampsia, post partum depression, etc)
Relocation: Is there any possibility of relocating to a different state in the next 18 months or during any time during the surrogacy?
If relocating, please explain the circumstances, state and when.
Are you on any state assistance? (Welfare, Medicaid, etc?)
Do you take any medications and/or supplements (prescription or OTC)?
Are you currently and/or have you ever been on medication for migraines, depression, anxiety, etc? If so, how long and how often?
Are you still taking any of those medications?
Do you know your blood type?
How did you hear about Midwest Surrogacy, LLC?
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