SURROGATE INTAKE FORM This form is lengthy, but worth it. Perseverance pays off. Typically takes between 3 to 5 minutes to complete Surrogate intake form-2 Step 1 of 4 25% This field is hidden when viewing the formName* First Last This field is hidden when viewing the formEmail* This field is hidden when viewing the formPhone*This field is hidden when viewing the formWhat state do you currently live in?*This field is hidden when viewing the formWhat county do you live in?This field is hidden when viewing the formWould you be interested in attending an event where you can hear from professionals and have all of your questions about surrogacy answered?This field is hidden when viewing the formAttend next eventThis field is hidden when viewing the formBring someoneThis field is hidden when viewing the formComments about eventThis field is hidden when viewing the formNotify of next eventThis field is hidden when viewing the formIf you were accepted into the program, how soon would you prefer to begin the process?* Right away 3 to 6 months 6 months to a year I need to, or would prefer to wait over a year before I begin None of the above, I am just looking This field is hidden when viewing the formWould you prefer to just be sent information at this time and complete this form at a later date?* I want to finish the form now and be sent information Send me information now, and I will return to complete this form when I'm ready This field is hidden when viewing the formWould you be interested in attending an event where you can hear from professionals and have all of your questions about surrogacy answered?*A chance to speak with experienced surrogates, IVF doctors, attorneys, and a surrogate agency in a fun and casual setting with food and drinks provided. Yes! Maybe Not interested This field is hidden when viewing the formWould you prefer to bring someone with you? Yes - Spouse/partner Yes - Family or friend No - I would attend on my own This field is hidden when viewing the formWhat days/times would work best for you?Check all that apply Weekday - daytime Weekday - evening Saturday - Morning Saturday - mid day Saturday - evening Sunday - morning Sunday - mid day Sunday - evening This field is hidden when viewing the formWho would you want to hear from?Check all that apply IVF Doctor - learn the details of the procedure Attorney - the contract and your rights Agency - overview of the entire process and understand the support you'll have Surrogates - hear from real experiences Spouses of surrogates - an insiders viewpoint This field is hidden when viewing the formIf we hold an event like this in your area, would you like to receive an invitation to attend? Yes! No thank you Age*Height*Weight*Occupation*Do you have any plans to move out of the state?* No Yes When and where do you think you'll be moving to?*What city do you live in?*Marital Status* Single In a relationship but not living together Living with a partner Engaged Married Separated Divorced Widowed Spouse / Partner's full name* First Last Do you speak and understand English?* Yes No Some What is your main language?* What type of birth control are you currently using?* Abstinence Condoms Tubal ligation Vasectomy Birth control pills IUD without hormones IUD with hormones Implant Depo-Prevera shot Nuva Ring Cervical cap or diaphragm Withdrawal or rhythm method Other Other - what type of birth control?*Date of most recent delivery*Are you currently breastfeeding?* Yes No When do you anticipate weaning your child?*How many pregnancies have you had?* 0 1 2 3 4 5 6 or more How many children have you given birth to?* 0 1 2 3 4 5 6 or more Of the children you have given birth to, how many currently live in your home?* 0 1 2 3 4 5 6 or more How many miscarriages have you had?* 0 1 2 3 or more Please provide approximate dates of miscarriage(s) and any details that might be relevant*How many abortions have you had?* 0 1 2 3 or more Please provide approximate year(s) of abortion*Please check all conditions you have experienced during any of your previous pregnancies or deliveries*Check all that apply Cesarean section Premature birth (4 weeks early or more) Pre-eclampsia (high blood pressure) Gestational diabetes Postpartum depression Placenta previa Placenta abruption Bed rest Home monitoring Pre-term labor Other - anything exceptional about any of your pregnancies or deliveries No problems Which pregnancy did you need bed rest for and what duration?How long did you experience post partum depression and what treatment did you receive?How many cesarean sections have you had?* 1 2 3 4 or more Please explain. Provide as much information as possible such as which pregnancy, level of severity and any details that might be relevant.* Do you have any current medical problems?* Yes No Please explain your current medical problems*Do you take any prescription and/or non prescription medications?* Yes No What medications are you taking?*Do either you or your partner have a criminal past with any arrests?*This does not necessarily prevent you from becoming a surrogate, but we do need to know about it right up front. Yes No Please explain:*Provide any pertinent information such as dates, conviction, any probation, etc. Do you have a history with previous drug use? Alcohol abuse? Or treatment?* Yes No Please explain your drug or alcohol history and any treatment.*Are you receiving any government assistance? Please check all that apply* Food assistance Health care assistance Housing assistance Utility assistance Child care subsidy Welfare, cash aid or supplemental income Other I am not receiving any government assistance Other - what type of assistance?*Are you a smoker? (Including the use of E-Cigarettes)* I currently smoke regularly I currently smoke socially I used to smoke I've never been a smoker When did you stop smoking?*Does anyone in your household smoke?* Yes Yes, but not inside the home No Do you have health insurance?*Health insurance is not a requirement Yes No What is the name of your insurance?*Have you been a surrogate, or have you met with an agency in the past?* Yes No Please provide the details of past surrogacy history, or efforts at becoming a surrogate*Please confirm:* The information I have provided is correct to the best of my knowledge One final question... Would you like our surrogate coordinator to contact you by phone to answer any questions or discuss your options?* Yes please! No thank you, not necessary No opinion Comments or Questions? Is there anything else you would like us to know? Or do you have any questions you would like for us to address? Δ
