Application for Surrogates - Surrogacy Center of Philadelphia

SURROGATE APPLICATION

Become a Surrogate

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Application Form - Surrogate

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1CONTACT INFORMATION

2BACKGROUND INFORMATION

3Personal Characteristics

4Medical History

5Personal Characteristics

Surrogate Name*

Email*

Mailing address*

City, State ZIP*

Phone number*

Best Time to Contact*

Date of Birth*

MM slash DD slash YYYY

Have you ever been a surrogate?*

If, so when?*

Present Employer

Present Occupation

Marital Status*

If married, how long have you been together?*

Spouse Name*

Spouse Birth Date*

MM slash DD slash YYYY

Spouse’s Employer*

Spouse’s Occupation*

Have you or your spouse ever?*

Filed Bankruptcy

Been turned down by an adoption agency

Been past due on child support

Been in a substance abuse program

Have current legal cases or claims pending

None of the above

Have you ever been convicted of a crime?*

Yes

Height*

Weight*

Is your bone structure*

What is the highest level of education that you have attained?*

What is your religion?*

Do you practice?*

What is your race? (Check All that Apply)*

White

Black

Hispanic/Latino

Asian

Hawaiian/Pacific Islander

American Indian/Alaska Native

Insurance Information

Insurance Carrier*

Effective Date*

MM slash DD slash YYYY

Name of Primary Insurance Holder*

How many successful pregnancies have you had?*

How many miscarriages have you had?*

Have you ever had a stillbirth?*

If, so when?*

Pregnancy #1

Child’s first name*

Child's Gender*

Date of Birth*

MM slash DD slash YYYY

Full term?*

Birth Weight*

Birth Delivery*

Weeks at Delivery*

Complications:*

Pregnancy #2

Child’s Second name*

Child's Gender*

Date of Birth*

MM slash DD slash YYYY

Full term?*

Birth Weight*

Birth Delivery*

Weeks at Delivery*

Complications:*

Pregnancy #3

Child’s third name*

Child's Gender*

Date of Birth*

MM slash DD slash YYYY

Full term?*

Birth Weight*

Birth Delivery*

Weeks at Delivery*

Complications:*

Pregnancy #4

Child’s fourth name*

Child's Gender*

Date of Birth*

MM slash DD slash YYYY

Full term?*

Birth Weight*

Birth Delivery*

Weeks at Delivery*

Complications:*

Pregnancy #5

Child's fifth name*

Child's Gender*

Date of Birth*

MM slash DD slash YYYY

Full term?*

Birth Weight*

Birth Delivery*

Weeks at Delivery*

Complications:*

Pregnancy #6

Child's sixth name*

Child's Gender*

Date of Birth*

MM slash DD slash YYYY

Full term?*

Birth Weight*

Birth Delivery*

Weeks at Delivery*

Complications:*

Pregnancy #7

Child's seventh name*

Child's Gender*

Date of Birth*

MM slash DD slash YYYY

Full term?*

Birth Weight*

Birth Delivery*

Weeks at Delivery*

Complications:*

Pregnancy #8

Child's eighth name*

Child's Gender*

Full term?*

Date of Birth*

MM slash DD slash YYYY

Birth Weight*

Birth Delivery*

Weeks at Delivery*

Complications:*

Pregnancy #9

Child's ninth name*

Child's Gender*

Full term?*

Date of Birth*

MM slash DD slash YYYY

Birth Weight*

Birth Delivery*

Weeks at Delivery*

Complications:*

Did you need medical assistance in achieving a pregnancy?*

Did you take more than 6 months to conceive your child(ren)?*

What is your current method of birth control?*

Are your menstrual cycles regular?*

Is there family history of fertility problems in your family?*

What is your daily activity level?*

What do you eat on a typical day?*

Do you smoke?*

Does anyone in your household smoke?*

Are you on any prescription medications?*

If yes, please indicate which ones and the reason:*

Do you take any non-prescription drugs?*

If yes, please indicate which ones and the reason:*

Have you been vaccinated against Hepatitis B?*

Have you been vaccinated against COVID-19?*

Do you drink alcohol?*

How often?*

Have you ever abused alcohol?*

Do you or have you ever used illegal drugs?*

Have you ever had to receive psychological counseling (including substance abuse counseling, marriage or family therapy)?*

If yes, please explain:*

Have you ever been under the care of a psychiatrist?*

If yes, please explain:*

Please list any significant illnesses you have had:*

Have you had or currently have any of the following conditions:*

Bleeding or Clotting Disorders

Cancer

Diabetes

High blood pressure

Gestational diabetes

Preeclampsia

Hepatitis

Seizure Disorder

Liver Disease

Kidney Failure

Thyroid Disease

None

Have you ever had surgery?*

If yes, please explain:*

Have you ever been hospitalized other than listed?*

Have you ever had major radiation or x-ray exposure?*

Have you ever had any jobs, hobbies, or activities that could have exposed you to chemicals, drugs, or gasses?*

When was your last physical exam?

Month*

Year*

Primary Care Physician Address:*

When was your last pap smear?

Month*

Year*

Were the results normal?*

OBGYN Address:*

Have you or your partner had any sexually transmitted diseases?*

If yes, please specify:*

Have you ever donated blood or had a blood transfusion?*

Describe your personality:*

What kinds of hobbies or activities do you enjoy?*

Please describe your future goals (personal and career):*

How do you manage stress in your life (particularly to periods that you have been pregnant)?*

Surrogacy Information

Have you applied to any other programs to be a surrogate?*

Are you willing to travel to another state for an embryo transfer procedure? (We only work with US clinics. All travel costs are fully covered by your Intended Parents).*

Are you willing to work with Intended Parents that live in another state?*

Are you willing to work with Intended Parents that live internationally?*

Briefly explain your personal reasons for wanting to be a surrogate:*

What qualities do you consider to be most important in choosing to work with prospective parents?*

Open to matching with: ( Check all that apply )*

Married couple

Partners

Single Person

LGBTQ

As a surrogate, would you have any concerns with the prospective parents participating in the birthing process?*

How do you feel being a gestational surrogate will affect your life? How might it prove difficult?*

How much contact would you like with the parents during pregnancy, delivery and after the child is born?*

During the surrogacy process, who can you expect to receive emotional support from?*

Is your partner aware of their responsibilities in the medical process and are they willing to cooperate (such as abstinence, testing)?*

What are your biggest concerns about becoming a gestational surrogate?*

Would you consent to prenatal testing for birth defects?*

Are you open to selective reduction in the event of high-order multiples?*

Are you open to termination in the case of a major medical issue or significant congenital malformation resulting in little or no life expectancy for the fetus?*

Are you open to termination in the event of a Down Syndrome diagnosis?*

Are you open to termination in the event of a chromosomal abnormality other than Down Syndrome?*

How many transfer attempts would you feel comfortable with in order to become pregnant?*

How many embryos are you open to transferring?*

SURROGATE APPLICATION

Application Form - Surrogate

Insurance Information

Pregnancy #1

Pregnancy #2

Pregnancy #3

Pregnancy #4

Pregnancy #5

Pregnancy #6

Pregnancy #7

Pregnancy #8

Pregnancy #9

When was your last physical exam?

When was your last pap smear?

Surrogacy Information

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