Initial Intake Form | The Surrogacy Consultant

For optimum performance, please complete this application using a CHROMIUM based browser (such as Chrome, Firefox, Brave etc.) Safari is NOT recommended. If you experience issues, please contact [email protected]

First Name

Last Name

Email

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Country

Street Address

City

State

Zip Code

Phone Number

What is your marital status?

Have you had at least one live birth?

Have you had more than 5 births?

Yes

No

Have you had more than 3 c-sections? (Individual clinics may require less)

Yes

No

What is your height?

'

"

What is your current weight?

lbs

Are you a US Citizen?

Are you a legal resident?

Do you smoke cigarettes or vape and/or is there smoking or vaping in the home? (candidates will be tested for nicotine)

When did you quit smoking/vaping?

Do you or anyone in the home use medical or recreational marijuana, illegal drugs, or prescription medication that is NOT prescribed to you? Surrogates are routinely tested for drug use.

Have you had preterm labor or delivery?

Please explain

Have you had pregnancy complications that include (but not limited to): Pre-eclampsia, gestational diabetes, blood clotting disorders, hyperemesis gravidarum, etc?

Please explain

Are you vaccinated for Covid-19?

Yes

No

No-but willing to

Are you on any form of government assistance?

Please explain.

Do you have a history of depression, post-partum depression, bipolar disorder or other mood disorder?

Please explain.

Are you willing to commit about 12 months to the process from start to finish?

How did you hear about The Surrogacy Consultant?

Please explain

Which Clinic can we thank for the referral?

Who can we thank for the referral?