Surrogate – Form

Ready to be surrogate for
Willing to travel
Do you hava a Passport
Hair color
Eye color
What is your U.S. citizenship status
Are you a member of the US military
Do you anticipate any change to your health insurance in the next year?:t
Have you ever been arrested
Have your partner ever been arrested
Would you terminate the pregnancy: If your health was at risk
If the fetus has Down syndrome and the intended parents chose to terminate the pregnancy
If has any other chromosomal issue and the intended parents chose to terminate the pregnancy
Would you be willing to reduce to do reduction if requested by the Parents or doctor
Do you have history of smoking during pregnancy
Have you ever tested positive for HIV
Do you drink alcohol excessively or use drugs of any kind
Have you or have anyone in your household been convicted a felony
Is any member of your household a registered sex offender
Taken any anti- depressants, anti- psychotics, or anti-anxiety medications in the past six months
Taken any anti- depressants, anti- psychotics, or anti-anxiety medications during pregnancy
Have you ever have a psychiatric hospitalization
Are you financial stable
Are you receiving any additional forms of government financial assistance
Have you ever had varicella
Have you previously received the varicella vaccine
Have you been vaccinated for measles, mumps and rubella (MMR)
Have you ever been immunized for Hepatitis B
If No, are you willing to be vaccinated prior to becoming a surrogate
Have you ever had a heterotopic or ectopic pregnancy
Did you have the fallopian tube removed
Are you current using any form of birth control
If you are using IUD, would you be willing to have it removed prior the medical screening
I accept terms and conditions