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PROSPECTIVE SURROGATES


Thank you for considering becoming a surrogate. By serving as a surrogate, you can help make one’s
most special dream come true and bring a new life into the world which would have never existed
without you.

To begin, please complete the initial questionnaire below so we can get to you know a bit about you. As
a next step, we’ll follow-up and have a more in-depth interview with you.

We’ll be in touch soon.

First Name: 

Last Name: 

Phone: 

E-mail: 

Street Address: 

City: 

State: 

Zipcode: 

Birthdate (in mm/dd/yyyy format): 

Height:

Weight:

What is your current relationship status?  

If in a relationship, is your spouse or partner aware and consenting of your serving as a surrogate:

Have you given birth before?

If yes, how many times?  time(s)

Have you ever served as a surrogate before?

If yes, how many times? time(s)

If yes, when?

Do you currently have children that you care for?

If yes, how many? children

If yes, how old are your children?

Have you ever had a C-Section?

If yes, how many C-Sections have you had? time(s)

If yes, when did you have a C-Section?

Have you ever had a miscarriage?

If yes, how many times have you had a miscarriage? time(s)

If yes, when did you have a miscarriage?

Have you used tobacco in the past year?

Have you used antidepressants in the past year?

Do you have a history of illegal drugs or alcohol abuse?

Are you currently taking any medications?

If yes, what medication and for what reason?

Do you currently receive any form of government assistance?

If yes, what kind of assistance do you receive?

Do you currently have health insurance?

If yes, who is your current health insurance carrier?

If yes, how long have you been under your current policy?

Do you currently have maternity coverage?

Please enter any questions or comments in the space below. Thank you for completing the
questionnaire.

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