Form

Contact Info:
Name:*
E-mail:*
Full Address:*
Phone*
Cell Phone:
Work Phone:
Where did you hear about RM?

Search Engine Surrogate Mothers Online Site EDSPA.ORG American Bar Association Clinic Referrral OB/GYN Referral Attorney Referral Referred by Friend Newspaper Magazine Radio Television Myspace Facebook
Myspace/Facebook:
Surrogacy Questions:
Application Type:
Have you ever been a surrogate before?
If yes, please describe your experience and the result:
Would you be willing to reduce the number of fetuses if asked?
Maximum number of fetuses you would carry:
How do you feel about termination?
How much compensation do you think is fair and reasonable for a surrogate of your type, experience, and background?
Health History:
What is your current height?
What is your current weight?
Have you had your tubes tied?

Yes No
What is your current method of birth control?
When were you last tested for HIV? Result?
When were you last tested for other STD? Results?
Please describe and give dates for any surgeries or major illnesses:
For each of your children list the following: name, year of birth, birth weight, gesational age at delivery, and delivery method:
Have you ever had any abortions, miscarriages, or still births? Please give appx dates:
Have you ever received fertility treatments in order to become pregnant?

Yes No
Please describe any difficulies women in your family have had getting pregnant or carrying a pregnancy to term:
Please describe any pregnancy/delivery complications, illnesses, difficulties:
RH +/-

Positive Negative Unsure
Are you a carrier of cystic fibrosis?

Yes No Unsure
Do you follow a special diet like vegetarianism, veganism, etc? Please explain:
Applicant Info:
Date of Birth
Month Day Year
Have you given birth to at least one healthy child?

Yes No
Are all of your children in your custody?

Yes No Shared legal Custody
Do you have reliable transporation?

Yes No Public Transportation
Are you currently receiving any of the following? Check all that apply:

Food Stamps Cash Assistance Medicaid for Self Medicaid for Children Not receiving public assistance
Are you taking antidepressants?

Yes No Not in the last 12 months
Do you smoke or use any tobacco products?

Yes No Not in the last 12 months
Do you drink alcoholic beverages?

Yes No Not when pregnant
Have you ever been charged with domestic violence, child endangerment, or any form of assult or battery?

Yes No
Have you ever been charged with a crime related to the use, posession, sale, or transport of drugs or drug paraphernalia

Yes No
Have you ever been charged with a crime involving theft, fraud, or similar?

Yes No
Work & Family:
Did you graduate from high school?

Yes No GED
Did you go to college?

I never went to college I went to college and received a degree I went to college but did not finish I plan to go back and finish someday I do not intend to go to college
If you received a degree, what was the degree?
Tell us abou what you do for a living:
What are your professional goals and do you see surrogacy helping you reach them?
How will being pregnant affect your work?
Are you married?

Married Single Dating In a long term relationship Living with Partner
Partner's Name:
How long have you been together?
How did your partner react to the idea of surrogacy or what do you think the reaction will be when you do tell them?
How did your children react when you told them about your plan to be a surrogate?
How will your obligations as a surrogate affect your family and their schedules (work, child care, school, etc)?
Closing Notes:
Check ALL family types you would consider:

Straight Married Gay Lesbian Single Man Single Woman Lives in my state Lives in a Neighboring State Lives on East Coast Lives on West Coast Lives in the US Lives Abroad White Black Interracial Hispanic Asian Native American Jewish Very Religious Somewhat Religious Secular All family types are okay
Is there any family type not listed above that you would be unwilling to work with?
Please use this area to write a letter to prospective parents telling them about yourself:
If you have any questions for RM staff, list them here. We will answer them during your interview.
Select a date for your intake interview using the calendar tool provided:
- Month - Day at Year / Hour Minutes
What time, on this day, should we plan to call?
Enter the phone number for us to call for this interview:
I understand that I will be required to pass a drug test before my application can be approved.*

I Agree.
I understand that I will be required to submit to a criminal background check before my application can be approved.*

I Agree.
I understand that I will be required to release certain medical records to RM staff relating to my previous pregnancies before my application can be approved.*

I Agree
I am aware that before I can proceed with a potential match, I will be required to undergo a psychological evaluation and a physical exam conducted by the fertility clinic.*

I Agree.
I am aware that if I am living with a romantic partner, he or she will be subject to some of the same screening measures listed above.*

I Agree.
Face Photo:
Full Length Photo:
Another Photo:
Family/Children Photo:
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Contact Info:

Surrogacy Questions:

Health History:

Applicant Info:

Work & Family:

Closing Notes: