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Apply to be a Surrogate
Personal Information
Tell us how we can reach you and learn a little about your background.
Full name
*
Email
*
Phone Number
*
Date of birth
*
Best way to contact you
*
Phone
Text
Email
Location
*
Do you have reliable transportation?
*
Yes
No
What is your ethnicity?
*
What is your religious affiliation?
*
What is your highest form of education?
*
Less than high school diploma
High school diploma or GED
Some college/ no degree
Associates degree
Bachelor degree
Masters degree
Higher than above listed
Height
*
Weight
*
Blood type
*
Health & Medical History
Please answer carefully. Your information will be reviewed confidentially.
Are you currently taking medications?
*
Allergies
*
Yes
No
If Yes, what allergies?
Do you smoke cigarettes, use any nicotine, THC products, or any form of recreational or illegal drugs/ substances?
*
Yes
No
Do you drink alcoholic beverages If so how often? (Please note that once you start your IVF medication before a transfer and while pregnant you may not drink alcohol.)
*
Do you have any history of substance abuse, or have you ever been in a substance abuse program? If so, please explain.
*
Have you ever been in a psychiatric facility? If so Please Explain.
*
Have you had any tattoos or piercings in the last 12 months?
*
Yes
No
Are you currently breastfeeding?
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Yes
No
Are your menstrual cycles regular?
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Yes
No
Date of last menstrual cycle
*
How many days between menstrual cycles
*
Date of your most recent pap smear
*
Do you have a history of STIs? If so, what STI's and when (if) were you cleared?
*
Past surgeries
*
Pregnancy History
Share your previous pregnancy and delivery experience.
How many pregnancies total?
*
List of all deliveries, including weeks at date of delivery, and delivery dates
*
Have you had any difficulty getting pregnant?
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Yes
No
Have you ever had any pregnancy complications? If so, what?
*
During pregnancy have you ever had any of the following
*
High blood pressure
Toxemia
Anemia
Preeclampsia
Pre-term labor
Premature rupture of membranes
Placenta acreta
Placenta abruption
Hyper emis
Hemorrhaging in labor
Infection
N/A
How long have you been considering Surrogacy?
*
Describe your diet
*
What forms of exercise do you do and how often?
*
Surrogacy Preferences
Help us understand your expectations and preferences for a surrogacy journey.
Select all of the following intended parents you will consider
Any couple
Married couple
Same-sex couple
Single parent
Caucasian
Hispanic
Asian
African American
Any race
With no children
with children
Frequent communication
No communication
Contact after birth
No contact after birth
Do you have previous experience as a Surrogate?
*
Yes
No
Are you willing to completely refrain from the use of alcohol, tobacco, marijuana, illegal drugs, and medications not authorized by a doctor during this surrogacy?
*
Yes
No
Do you have history of substance abuse?
*
Yes
No
Are you willing to reduce or eliminate your caffeine intake while you’re pregnant? (e.g. tea, coffee, energy drinks and soda)
*
Yes
No
During the pregnancy you will not be permitted to travel outside of your state after approximately 20 weeks of pregnancy. Will this be feasible for you?
*
Yes
No
If serious health problems, genetic malformations or birth defects were detected during the pregnancy, would you be willing to terminate at the request of the intended parents?
*
Yes
No
When a transfer results in a pregnancy of more than twins many physicians recommend selective reduction and many intended parents prefer to reduce the pregnancy to twins. Are you willing to undergo a selective reduction to twins to increase the chances of survival for the remaining babies and for your safety and well-being?
*
Yes
No
Are you willing to travel out of the state, for the transfer, for up to 5 days?
*
Yes
No
Will you be willing to allow the intended parents to attend appointments and delivery?
*
Yes
No
Some surrogates pump breast milk following the delivery and are compensated by the intended parents. Are you interested in pumping for your surrogate baby?
*
Yes
No
Some intended parents live far away from their surrogates. If your intended parents can’t see you regularly make it to appointments or delivery would that be okay with you?
*
Yes
No
Are you willing to come to the Los Angeles area for your OBGYN screening and preparation. (Travel expenses will be reimbursed)
*
Yes
No
Lifestyle & Legal
A few final questions about your lifestyle, background, and matching readiness.
What is your occupation?
*
Describe your lifestyle, hobbies, etc.
*
Describe your home life
*
Are you a US citizen?
*
Yes
No
Do you have a valid driver’s license?
*
Yes
No
Have you ever filed for bankruptcy?
*
Yes
No
Do you have a criminal history?
*
Yes
No
Have you ever been arrested? If so, explain
*
Do you have American Indian heritage?
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Yes
No
Relationship status
*
Single
Relationship
Married
Divorced
Partner & Support System
Tell us about your household, partner, and support network.
Spouse/partner’s name
*
Spouse/partner’s date of birth
*
Does your partner have a history of substance abuse?
*
Yes
No
Does your partner have a history of psychiatric care?
*
Yes
No
Do you have a local support system?
*
Yes
No
Is there anyone in your support group that does not support your choice to become a Surrogate?
*
Yes
No
Who currently resides in your home?
*
How many sexual partners have you had in the last 6 months?
*
What compensation are you hoping for for your journey?
*
Describe why you are interested in becoming a Surrogate?
*
Photos & Supporting Files
Upload up to 10 photos or supporting documents. Accepted formats include JPG, PNG, HEIC, WebP, and PDF.
Please upload a few photos that show you, your personality, and your family
Drag and Drop (or)
Choose Files
Consent and acknowledgement
*
I confirm that the information provided is accurate and I agree to the
Privacy Policy
.
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