GC - Intake Form

1Personal Information
2Spouse/Partner Information
3Basic Information
4Health Information
5Pregnancy History

First Name

Last Name

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Are you a US or Canadian citizen?

State

Phone Number

Height

Weight (in pounds)

lbs

How did you hear about us?

Do you speak and understand English fluently?

Do you live outside of California, Arizona, or Nevada?

Do you have a spouse/partner?

Do you smoke?

Do you use nicotine in any form?

Does anyone else in your household smoke, vape, or use marijuana in the form of smoke or vape?

If anyone in your household currently smokes/vapes inside the home, they will be required to do so outside the home during the surrogacy process.

Do you use marijuana?

Have you used illicit drugs in the last 12 months?

Do you drink alcohol?

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

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

Date of last physical exam?

Sun Mon Tue Wed Thu Fri Sat

Have you ever donated blood?

Have you ever been excluded from blood donations due to infectious disease?

Have you been vaccinated for Hepatitis B?

Have you received the COVID vaccine?

Blood Type

Are you currently taking any medication?

Have you ever taken Accutane?

Have you previously had any surgery?

Have you ever had problems with anesthesia?

Have you ever had cancer?

Do you have any current or previous health conditions that need to be addressed?

Please describe your diet.

Do you exercise?

In the past 12 months, have you received blood transfusions, blood injections, tattoos, or piercings?

Are you willing to refrain from having any tattoos during the cycling and pregnancy process?

How many deliveries have you had?

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

How many c-sections have you had?

Have you ever had difficulty getting pregnant?

Have you ever used fertility medications?

Have you been diagnosed with gestational diabetes in the past?

Have you been diagnosed with preeclampsia in the past?

Year of last PAP smear.

Results of last PAP smear.

Are you currently on birth control? (If you are currently using a hormonal IUD, you will be required to remove it and get on the pill. Scheduling with your primary physician during the early stages of the admissions process will speed up the matching process.)

Do you have regular menstrual cycles?

When was the first day of your last menstrual cycle?

Sun Mon Tue Wed Thu Fri Sat

Do you require a RhoGAM shot during pregnancy?

Are you currently breastfeeding?

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