Surrogate Initial Application

1Personal Information
2Basic Information
3Health Information
4Pregnancy History

First Name

Last Name

Maiden Name (for medical record purposes)

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Are you a US or Canadian citizen?

State

Phone Number

I agree to receive informational SMS/text messages from Road To Baby at the number provided. Message frequency varies. Msg & data rates may apply. Consent is not required to continue. Reply STOP to opt out.

Are you shorter than 4'11" or at 4'11"?

Height

Weight (in pounds)

lbs

When are you looking to start your surrogate journey?

How did you hear about us?

Referral information provided is considered final. Referrals cannot be changed, altered, or added after submission under any circumstance.

I understand.

Have you applied and been denied at a different agency?

Do you speak and understand English fluently?

Do you smoke?

Do you use nicotine in any form?

Do you use marijuana?

Have you used ANY illicit drugs in the past at all?

(examples: Cocaine/Crack, Heroin, MDMA/Ecstasy, Fentanyl, Methamphetamine, PCP, Ketamine)

Will you allow us to conduct a background check on you?

Do any of your own children live at home with you?

Are you currently taking any medication?

Have you previously had any surgery?

Have you even been seen (in-patient OR out-patient) at a rehabilitation facility for drugs or alcohol?

Has your spouse or partner ever been seen (in-patient OR out-patient) at a rehabilitation facility for drugs or alcohol?

How many deliveries have you had?

How many pregnancies have you had? This includes miscarriages, stillbirths, live births.

Have you had any abortions? If so, list dates . Please note: complete transparency is needed.

How many c-sections have you had?

Have you been diagnosed with gestational diabetes in the past?

Have you been diagnosed with preeclampsia in the past?

Was your last pregnancy full term (37 weeks or more)?

Was your last full term delivery over 10 years ago?