Your Name (required)

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Your Email (required)

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Phone Number(required)

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Your City(required)

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Your State(required)

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Your Country(required)

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Do You Have a Webcam YesNo
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Date of Birth

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By checking the box below, you acknowledge the importance of honest and complete answers to the questions asked. We use the application to complete the screening process and find the best match options for you.
Yes
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US Citizenship Status
US CitizenPermanent Citizen/Green Card HolderTemporary Citizen/Visa HolderNot a Citizen/No Green Card
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Ethnic Background
American Indian/Alaskan NativeAsianBlack or African AmericanHispanic or LatinaHawaiian or Other PacificIslanderWhiteOther
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Marital Status
MarriedEngagedRelationship (co-habitating)Relationship (living separately)SingleDivorcedLegally SeparatedSeparated(Non-legally)
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Name of Partner or Spouse, if any

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List of all marriage & divorce dates, write NONE if you have never been married


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Are you Religiously Affiliated?
YesNo
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How Did you Hear About Us

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ADDITIONAL QUALIFYING QUESTIONS
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Have You Given Birth Before?
YesNo
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Are you currently pregnant? (If yes, you can still apply but please note that you will be placed on hold until after your delivery.)
Yes, I'm PregnantNo, I'm Not Pregnant
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Have you had more than 3 C-sections?
YesNo
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Have you had more than 2 miscarriages?
YesNo
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Are you currently a member of the US military?
Yes, I'm Currently ActiveYes, I'm No Longer ActiveNo
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Is your partner a member of the U.S. military?
Yes, He/She is Currently ActiveYes, He/She is No Longer ActiveNo
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If it were medically advisable to terminate the pregnancy because your health was at risk, would you agree to terminate?
YesNo
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If it were medically determined that the fetus has Down syndrome and the intended parents chose to terminate the pregnancy, would you be willing to terminate the pregnancy at their request?

YesNo
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If it were medically determined that the fetus has a chromosomal abnormality other than Down syndrome, such as spina bifida, and the intended parents chose to terminate the pregnancy, would you be willing to terminate the pregnancy at their request?

YesNo
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Although extremely rare, a pregnancy of triplets or more is considered high risk. In this situation, would you be willing to reduce to twins if requested to do so by the IPs or if deemed medically advisable for your health or the health of the children?

YesNo
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In the case of a pregnancy with multiples, if one fetus had a chromosomal abnormality/genetic condition/medical diagnosis that would affect quality of life, would you agree to selectively reduce if advised by a doctor and/or at intended parents' request?

YesNo
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BMI
Height:


Weight (lbs):


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Have you ever tested positive for HIV?
YesNo
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Have you previously had chicken pox or received the varicella (chicken pox) vaccine? (required)
I have had chicken pox.
I received the varicella vaccine.
I have neither had chicken pox nor received the vaccine, but I am willing to be vaccinated prior to becoming a surrogate.
I have neither had chicken pox nor received the vaccine and I am not willing to be vaccinated prior to becoming a surrogate.
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Have you been vaccinated for MMR (measles, mumps, rubella)?(required)
Yes
No, I have not had the MMR vaccine, but I am willing to be vaccinated prior to becoming a surrogate.
No, I have not had the MMR vaccine and I am not willing to be vaccinated prior to becoming a surrogate.
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Have you ever been immunized for Hepatitis B?(required)
Yes
No, I have not been immunized for Hepatitis B, but I am willing to be vaccinated prior to becoming a surrogate.
No, I have not been immunized for Hepatitis B and I am not willing to be vaccinated prior to becoming a surrogate.
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Were you ever a tobacco Smoker?
Yes, Presently
Yes, Previously
No
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Do you currently smoke cigarettes or use tobacco products? (Please note: medical screening of surrogates includes a nicotine test.)

YesNo
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Do you have any history of smoking cigarettes or using tobacco products during any of your prior pregnancies? (NOTE: This will be verified on your medical records.)

YesNo
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Do you currently use recreational drugs or drink alcohol excessively?

YesNo
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Do you have a history of recreational drug use or alcohol abuse?

YesNo
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Have you taken any anti-depressants, anti-psychotics, or anti-anxiety medications in the past six months?

YesNo
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Have you ever taken anti-depressants, anti-psychotics, or anti-anxiety medications during a pregnancy? (Note: we will request medical records.)

YesNo
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Have you ever had a psychiatric hospitalization? If yes, when, where, and for how long?

Yes, before age of 18
Yes, after age of 18
No

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Has any member of your current household ever been diagnosed with any of the following mental illnesses: Schizophrenia, Bipolar Disorder, Severe Post-Partum Depression or Post Traumatic Stress Disorder? If yes, list who and give details.

Yes, before age of 18
No

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Have you ever been diagnosed with any of the following? Check all that apply. (Please note: review of medical records is part of the screening process.)
Schizophrenia and/or Bipolar Disorder
Severe Post-Partum Depression
Post Traumatic Stress Disorder
None of the Above
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Have you or anyone in your household been convicted of a felony? (Please note: screening will involve a criminal background check on all adults in your household.)

YesNo
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Is any member of your household a registered sex offender?

YesNo
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Are you financially stable?

YesNo
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Are you receiving any of the following additional forms of government financial assistance?

Yes
No

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