Become a Surrogate | Application

Surrogacy Application

"*" indicates required fields

1Basic Information

2Health History

3Medical History

4Personal History

5Confirmation

Tell Us About Yourself

First Name*

Last Name*

Email*

Enter Email Confirm Email

Street Address*

City*

State*

Zip Code*

What is the closest major city to where you live?*

Date of birth*

MM slash DD slash YYYY

Age*

Best Contact Phone Number*

Is it okay to leave a message to the best contact?*

Yes

Second Contact Phone Number

Is it okay to leave a message to the second contact ?

Yes

Ethnicity*

Religious background*

Height Feet*

Please enter a number less than or equal to 12.

Height Inches*

Please enter a number less than or equal to 12.

Weight*

BMI Calculated

Marital status*

Are you currently enlisted in the Military*

Yes

Is your spouse currently enlisted in the Military*

Yes

Are you currently employed*

Yes

If yes, what is your occupation*

Do you have your high school diploma or GED*

Yes

Please list in detail your level of education beyond high school*

Tell Us About Your Health History

Do you have any medical problems? If so, please explain in detail*

Have you ever had any surgeries? If so please provide details for each surgery*

Have you given birth before*

Yes

Number of pregnancies (please include miscarriages and abortions)*

Number of children*

Please list the age(s) of your child(ren)*

Have you delivered a child vaginally*

Yes

Have you had a cesarean (c-section)*

Yes

Please provide details on the cesarean*

Please specify if you have had any of the following complications throughout any of your past pregnancies:

Placenta Previa*

Yes

Please provide details on the Placenta Previa*

Toxemia*

Yes

Please provide details on the Toxemia*

Pre-Eclampsia*

Yes

Please provide details on the Pre-Eclampsiaa*

Anemia*

Yes

Please provide details on the Anemia*

Pregnancy-induced hypertension*

Yes

Please provide details on the Pregnancy-induced hypertension*

Gestational Diabetes*

Yes

Please provide details on the Gestational Diabetes

Have you been a surrogate mother before*

Yes

how many times have you been a surrogate mother before*

Do you smoke or use tobacco*

Yes

Have you ever used a mind altering drug such as marijuana, cocaine, heroin, ecstasy, LSD or methamphetamines? If so, please explain which drug, frequency of use, and last date used*

Have you used any illegal drugs in the past 12 months*

Yes

Please provide details on the illegal drugs used*

Have you ever been a member of a drug or alcohol treatment program*

Yes

Please provide details of the drug or alcohol treatment program*

Are you currently taking any medications? If yes, please list each medication and the reason the medication has been prescribed to you*

Number of sexual partners in your lifetime*

Number of sexual partners in the past 12 months*

Number of sexual partners in the past 30 days*

Have you or your partner tested positive for Chlamydia in the past 12 months?*

Yes

Please provide more detail about the Chlamydia*

Have you or your partner tested positive for Gonorrhea in the past 12 months?*

Yes

Please provide more detail about the gonorrhea*

Have you or your partner tested positive for Syphilis in the past 12 months?*

Yes

Please provide more detail about the syphilis*

Have you or your partner tested positive for HIV/AIDS?*

Yes

Please provide more detail about the HIV/AIDS*

Have you ever been diagnosed with Genital Herpes?*

Yes

Please provide more detail about the Genital Herpes*

Have you received a tattoo in the past 12 months?*

Yes

Please provide more detail about the tattoo*

Have you received a piercing in the past 12 months?*

Yes

Do you currently have health insurance?*

Yes

If so, who is your insurance provider (i.e. Aetna, BlueCross) and what type of coverage do you have (i.e. HMO, PPO)?*

When was your last pap smear and what was the result (if abnormal what was your doctors suggested course of action?)*

Tell Us About Your Personal History

Are you currently receiving any type of government assistance?*

Yes

Have you ever been arrested?*

Yes

Have you ever received a DUI or DWI?*

Yes

Have you or your partner ever been convicted of a felony?*

Yes

Have you ever been diagnosed as clinically depressed?*

Yes

Have you ever been diagnosed with post-partum depression?*

Yes

Have you ever been prescribed anti-depressants?*

Yes

Have you ever been prescribed anti-anxiety medication?*

Yes

Have you ever attempted suicide?*

Yes

Have you ever had a child removed from your home?*

Yes

Have you ever lost custody of a child?*

Yes

Have you ever been a victim of domestic violence?*

Yes

If your application is approved are you (and your spouse if applicable) willing to have a full background check conducted and released to Family Creations?*

Yes

Are you willing to undergo a home visit conducted by a Family Creations staff member?*

Yes

How did you hear about us?*

Friend/Family First Name*

Friend/Family Last Name*

Please upload a recent photograph of yourself. Applications with photographs submitted will be processed faster.

Accepted file types: jpg, jpeg, png, gif.

I agree that I represent that all written representations and information provided and/or to be provided to Family Creations, LLC, and any professional, psychologist, physician, physician's assistant, nurse, attorney, or designee of Family Creations, are true, correct and complete.*

Click this check box if you agree

Confirmation

Thank you for your interest in Family Creations. Please create a password. You will use this password to login to your account, update your profile and submit required documentation

Password

Enter Password Confirm Password

Surrogate Application

Surrogacy Application

Tell Us About Yourself

Tell Us About Your Health History

Please specify if you have had any of the following complications throughout any of your past pregnancies:

Tell Us About Your Personal History

Confirmation

Featured In

Surrogacy Application

Tell Us About Yourself

Tell Us About Your Health History

Please specify if you have had any of the following complications throughout any of your past pregnancies:

Tell Us About Your Personal History

Confirmation

Featured In

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