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Surrogate Application Form

Surrogate Application

Begin Your Surrogacy Journey

Thank you for considering Blessing Surrogacy. Please complete this secure application carefully. Your information will be reviewed confidentially by our team.

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 *PhoneTextEmail

Location *

Do you have reliable transportation? *YesNo

What is your ethnicity? *

What is your religious affiliation? *

What is your highest form of education? *Less than high school diplomaHigh school diploma or GEDSome college/ no degreeAssociates degreeBachelor degreeMasters degreeHigher 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 *YesNo

If Yes, what allergies?

Do you smoke cigarettes, use any nicotine, THC products, or any form of recreational or illegal drugs/ substances? *YesNo

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? *YesNo

Are you currently breastfeeding? *YesNo

Are your menstrual cycles regular? *YesNo

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? *YesNo

Have you ever had any pregnancy complications? If so, what? *

During pregnancy have you ever had any of the following *High blood pressureToxemiaAnemiaPreeclampsiaPre-term laborPremature rupture of membranesPlacenta acretaPlacenta abruptionHyper emisHemorrhaging in laborInfectionN/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 considerAny coupleMarried coupleSame-sex coupleSingle parentCaucasianHispanicAsianAfrican AmericanAny raceWith no childrenwith childrenFrequent communicationNo communicationContact after birthNo contact after birth

Do you have previous experience as a Surrogate? *YesNo

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? *YesNo

Do you have history of substance abuse? *YesNo

Are you willing to reduce or eliminate your caffeine intake while you’re pregnant? (e.g. tea, coffee, energy drinks and soda) *YesNo

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? *YesNo

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? *YesNo

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? *YesNo

Are you willing to travel out of the state, for the transfer, for up to 5 days? *YesNo

Will you be willing to allow the intended parents to attend appointments and delivery? *YesNo

Some surrogates pump breast milk following the delivery and are compensated by the intended parents. Are you interested in pumping for your surrogate baby? *YesNo

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? *YesNo

Are you willing to come to the Los Angeles area for your OBGYN screening and preparation. (Travel expenses will be reimbursed) *YesNo

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? *YesNo

Do you have a valid driver’s license? *YesNo

Have you ever filed for bankruptcy? *YesNo

Do you have a criminal history? *YesNo

Have you ever been arrested? If so, explain *

Do you have American Indian heritage? *YesNo

Relationship status *SingleRelationshipMarriedDivorced

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? *YesNo

Does your partner have a history of psychiatric care? *YesNo

Do you have a local support system? *YesNo

Is there anyone in your support group that does not support your choice to become a Surrogate? *YesNo

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.

(+1)8053589019

We'd love to hear from you

Head Office
10390 Santa Monica Blvd, Ste 370, Los Angeles, CA 90025
(+1)8053582997
(+86)2160459035
surrogate@blessingsurrogacy.com

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Email *

We'd love to hear from you

Head Office10390 Santa Monica Blvd, Ste 370, Los Angeles, CA 90025

(+1)8053582997

(+86)2160459035

surrogate@blessingsurrogacy.com

Get Started
About Us
Privacy Policy
Terms & Conditions
Log In

Do you want to reach out to us? Leave your information and we will contact you shortly.

Please enable JavaScript in your browser to complete this form.

Email *