Surrogate Form | Southern California Surrogacy Please feel free to contact us if you have any questions about our surrogacy program or the process involved. We look forward to hearing from you! First Name* Last Name* Email* Phone* What is the best way to contact you? (optional)- Select One -EmailPhoneText CountryUnited States Address Line 1* Address Line 2 (optional) City* State* - Select One -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code* Are you a citizen or permanent resident of the US?*- Select One -CitizenPermanent Resident When is your date of birth?* Height (ft) (optional) Weight (lbs) (optional) What is your BMI? (weight/height)* What is your legal marital status? (optional)- Select One -SingleMarriedEngagedDivorced What is your partner/spouse's legal name? (optional) How many years have you been legally married? (optional) Who is your partner/spouse's employer? (optional) What is his/her title/position? (Please describe) (optional) Please list the first name, age, and relationship to you of everyone who you live with, including children(optional) Please specify your ethnicity (optional) Continue Have you applied to any other agencies? (optional)- Select One -YesNo If yes, please describe. (optional) How did you hear about us? (optional) Who is your present employer? (optional) Are you required to do heavy lifting at work? (optional)- Select One -YesNo If yes, how many Ibs? (optional) Do you have medical insurance? (optional)- Select One -YesNo What is the name of your health insurance carrier? (optional) How many days per week do you use tobacco in any form? (optional) How many days per week does your partner/spouse or roommate smoke per week? (optional) How many days per week do you drink alcoholic beverages? (optional) When is the last time you had marijuana? (optional) When is the last time you have used recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)? (optional) Have you ever been diagnosed with herpes? (optional)- Select One -YesNo Have you ever been diagnosed with gonorrhea? (optional)- Select One -YesNo Have you ever been diagnosed with chlamydia? (optional)- Select One -YesNo Have you ever been diagnosed with syphilis? (optional)- Select One -YesNo BackContinue Have you ever been diagnosed with HPV? (optional)- Select One -YesNo Have you ever been diagnosed with genital warts? (optional)- Select One -YesNo Has your partner / spouse ever been diagnosed with gonorrhea, chlamydia, syphilis, HPV, genital warts or herpes? (optional)- Select One -YesNo Please list any surgeries you have had. (Surgery, Year, Reason for Surgery, & Outcome) (optional) Please list any medications you are currently taking. (optional) Please list any CURRENT medical conditions. (optional) Please list any PAST medical conditions. (optional) Do you have or have had asthma? (optional)- Select One -YesNo Do you have or have had depression? (optional)- Select One -YesNo Do you have or have had diabetes? (optional)- Select One -YesNo Do you have or have had eating disorders? (optional)- Select One -YesNo Do you have or have had heart problems? (optional)- Select One -YesNo Do you have or have had high blood pressure? (optional)- Select One -YesNo Do you have or have had migraine headaches? (optional)- Select One -YesNo How many pregnancies have you had?* How many miscarriages have you had?* How many abortions have you had?* How many living children do you have? (optional) How many children with physical birth defects have you had?* How many children with mental health defects have you had?* BackContinue Please provide the following information regarding ALL pregnancies including abortions and miscarriages (enter "n/a" if never been pregnant). Please describe any problems with any pregnancy, delivery or birth. Please include any birth defects or issues associated with any children.* What is the date of your last delivery?* What kind of birth control do you use?* If you have an IUD, do you agree to schedule an appointment as soon as possible to remove it?*- Select One -YesNoN/A Do you have a menstrual cycle every month?*- Select One -YesNo How many days are between your periods?* What is the date of your last menstrual cycle?* What was the date of your last Pap Smear?* What was the result of your last Pap Smear?* Have you had a Hep B vaccination? (optional)- Select One -YesNo When was the date you were vaccinated for Hep B? (optional) What was the result of your Hep B? (optional) What is your Blood Type? (optional) What is your highest level of completed education? (optional)- Select One -High SchoolSome CollegeBachelor's DegreeMaster's DegreePHD Have you ever placed a child up for adoption? or have you ever given custodial rights to someone else? If so who? (optional) Have you ever been sexually assaulted? (optional)- Select One -YesNo Have you ever had psychological counseling? (optional)- Select One -YesNo Have you ever been convicted of a crime? If yes, please explain (including year) (optional) Has your partner ever been convicted of a crime? If yes, please explain (including year) (optional) BackContinue Have you ever been arrested, including a DUI arrest? If yes, please explain (including year) (optional) Do you currently have any legal cases or claims pending? (optional)- Select One -YesNo Do you understand you will need to ultimately submit to us a copy of your obstetric records from your prior pregnancies and deliveries, your most recent physical exam results from your primary care provider, along with a Pap smear results and any other tests that were completed? (optional)- Select One -YesNo With the understanding that expenses are paid by the recipient(s), would you be willing to travel by car to a neighboring city for appointments? (optional)- Select One -YesNo With the understanding that expenses are paid by the recipient(s), would you be willing to travel by plane to another city for appointments? (optional)- Select One -YesNo From which family types would you be willing to carry a child? (optional) Would you be willing to carry a child for a recipient(s) who are over 50 years old? (optional)- Select One -YesNo Would you be willing to carry a child whereby the recipients used donor egg or donor sperm?*- Select One -YesNo Would you be willing to carry a child for a recipient(s) who will raise this child in a religion different from your own?*- Select One -YesNo Would you be willing to undergo genetic testing? (optional)- Select One -YesNo Would you be willing to terminate the pregnancy if there should be a significant qualify of life issue?*- Select One -YesNo Based on the preference of the intended parent/s beliefs and in the best interest of the child, would you be willing to terminate the pregnancy?*- Select One -YesNo Are you willing to carry for an Intended Parent/s who have Hep B?*- Select One -YesNo Would you be willing to carry for an Intended Parent(s) that is HIV Positive?*- Select One -YesNo You will be required to take IVF medications. Some meds require using injectable needles. Do you agree to take ALL medications required?*- Select One -YesNo Are you willing to transfer more than 1 embryo?*- Select One -YesNo Are you willing to carry twins or more, if an embryo should split?*- Select One -YesNo We prefer to do a total of 3 transfers attempts if unsuccessful. Are you okay with this?*- Select One -YesNo If you happen to have triplets or more, would you be willing to have a "selective reduction" (Terminate 1 or more specific fetuses to achieve twins)? If yes, please specify what selective reduction options you are willing to agree to.* Who are you willing to have on Ob/Gyn appointments?* Who are you willing to have on Fertility Center appointments?* Back
