Surrogacy Pre-qualification Questionnaire First Name* Last Name* Email:* Phone: Date of Birth* Height* Weight* What state do you live in? Are you a citizen or permanent resident of the US?* CitizenPermanent ResidentNeither Are you on any form of government assistance? (i.e. MedicAid, Food Stamps, Housing Subsidies, etc.) YesNo Are you Covid vaccinated? YesNo Are you willing to get Covid vaccine? YesNo How many deliveries have you had?* What were the gestational weeks at delivery? Have you had more than 3 C-sections? YesNo Any type of anxiety, depression, or postpartum depression? YesNo Any complications during pregnancy? (i.e. High Blood Pressure, Gestational Diabetes, Preeclampsia, etc.) Are you ready to become a surrogate, or just looking for more information?* I'm readyJust looking for more information