General Information Full Legal Name
Other names used in the past
Mobile/Cell no
Email
Home address
City
Zip Code
State
Country
Date of Birth
Relationship Status
Single In a relationship Engaged Married It's complicated In an open relationship Widowed Separated Divorced Other Do you have health insurance? Who is your insurance carrier?
What is your weight?
What is your height?
Do you belong to a Native American tribe? Do you have a high-school diploma? What is your occupation?
Who is your employer?
What is your average weekly income?
Family and Relationships How many children do you have?
Please list the first names, genders and ages of all your children
If yes, please let us know...
What is your partner's full name?
Partner's date of birth?
Partner's email address?
Partner's occupation?
Your Partner's employer?
Your Partner's average weekly income?
How many times have you been married?
Is your current parnter the biological parent of all your children?
Yes No I don't have any Children If no, please provide more details...
Do you have custody of all your children?
Yes No I don't have any Children If no, please provide more details...
Are there any other adults that live in your household? If yes, please provide more details...
Have you lived ouside the U.S? If yes, please specify where and for how long...
Are you a legal U.S citizen? If no, do you have legal, permanent residency? Have you (or anyone you live with) ever been investigated by child protective services? If yes, please provide details and dates...
Do you (or anyone you live with) currently have any legal cases or claims pending? If yes, please provide details...
Have you (or anyone you live with) ever been arrested? If yes, please provide details...
Do you (or anyone you live with) have any outstanding tickets or warrants? If yes, please provide details...
Do you (or anyone you live with) have any history with drug or alcohol abuse? If yes, please provide details...
Have you (or anyone you live with) ever filed for bankruptcy? If yes, please provide details...
Mental Health History Have you ever gone to therapy or counseling? If you have selected yes, please provide the following details...
Reason for attending:
How often you attended:
When your last session was:
Date you stopped:
Reason for stopping:
Have you ever been prescribed or taken medications to treat a mental health issue such as depression, schizophrenia anxiety, bipolar disorder, ADHD, etc? If you have selected yes, please provide the following details...
Reason for medication:
Name of medication:
Date you started medication:
Date you stopped using medication (if applicable):
Reason for stopping medication (if applicable):
Have you ever been diagnosed with an eating disorder? If yes, please provide details and dates:
Have you ever attempted suicide? Have you ever been hospitalized for a psychiatric condition or been placed on a psychiatric hold? If yes, please provide details and dates:
Have you ever attended an inpatient or outpatient substance-abuse treatment program? If yes, please provide details and dates:
General Health Date of last physical?
Have you been treated for any medical conditions in the past If yes, please provide details and dates:
Have you had any surgeries in the past? If yes, please provide details and dates:
Please list all medications you are using (including over the counter medication or herbal supplements)
Are you currently under the care of a physician? If yes, please provide details:
Have you ever been hospitalized? If yes, please provide details:
Are you willing to self-administer injectable medications? If required during medical screening, would you be willing to get Measles, Mumps, Rubella and Chicken Pox vaccine? If required during medical screening, would you be willing to get the flu or TDAP (Whooping Cough) vaccine? Have you been vaccinated for Covid-19? Have you recived a booster for Covid-19? If requested by the intended parent(s) would you be willing to be vaccinated for Covid-19? Have you ever tested positive for Covid-19? If yes, when was your last positive result?
Reproductive Health Date of last PAP smear
Have you ever had an abnormal pap smear? If yes, when and what was the reason it was abnormal?
Are you currently using any form of birth control? If yes, what kind? (if using IUD please list which kind)
Have you ever had an IUD or Depo-Provera? If yes, when was it removed or last used?
Have you resumed a regular menstrual cycle? What type of birth control have you used in the past?
Are your menstrual cycles regular/recurring? If no, please explain
How long are your menstrual cycles? (ie. 28 days)
How long does your period last? (ie. 5 Days)
Are you willing to take hormonal birth control if prescribed by the fertility doctor? If no, please explain
Are you currently breastfeeding? If yes, when do you plan to discontinue breastfeeding?
Did you have trouble conceiving your own children? If yes, please explain
Do you plan on having more children of your own? If yes, how many more?
Did you need any medical assistance (ie. IVF) to conceive your own children? If yes, please explain the reason why and what clinic you used in detail
Have you ever had an STD? If yes, please provide details and dates
Pregnancy How many times have you been pregnant?
Number of vaginal births
Number of c-section births
Number of miscarriages
Number of terminations
Please list the location of the hospital/s where you delivered and/or received OB care
Please list the dates, weight, gestational age and any complications for each live birth
Have you ever been a surrogate before? If yes, please answer the following questions...
How many of your pregnancies were surrogate?
Please list the names of the IVF clinics and Doctors you saw, in chronological order for each surrogate pregnancy (ie. first surrogacy: John Doe at NFC etc.)
Please list transfer dates for each surrogacy in chronological order
Please list the number of embryos transferred for each surrogacy in chronological order
Please list the outcome of each surrogacy in chronological order
Is there anything you dislike about being pregnant?
Lifestyle Please describe what you eat in a typical day?
Any dietary restrictions or eating habits you would like to share? (eg. vegan, vegetarian or gluten free diet)
If yes, please explain how often and what your routine is?
If yes, please describe what kind and how often
Are you willing to limit or stop drinking caffeine during pregnancy if requested by the clinic or OB? Do you drink any alcoholic beverages? If yes, please describe what kind and how often
If yes, are you willing and able to stop drinking alcohol during pregnancy Do you, or anyone you live with, currently use tobacco products? If yes, please describe what kind and how often
Do you currently use any products that contain THC (marijuana) If yes, what is it for?
If yes, are you willing to discontinue use of THC products for surrogacy? Do you or your partner smoke anything? Does anyone smoke in your house? How many sexual partners have you had in the last 12 months?
Have you had any body modifications in the last 12 months? (ie. piercings, tattoos, implants etc.) If yes, please list what you’ve had done and when
Do you have any pets at home? If yes, are you willing & able to wear gloves or have someone help with cleaning up your pets feces? What is your main mode of transportation?
Do you have a valid driver's license? If no, please explain
Do you have auto insurance? If no, please explain
Have you traveled outside of the U.S. in the past 24 months? If yes, when and where did you go?
Do you plan on traveling in the next 18 months? If yes, when and where?
After about 24 weeks of pregnancy most contracts will require that you remain in your home state. Are you okay with these restrictions?
Would you consider carrying twins if the embryo splits? Are you willing to undergo multiple transfers if needed to achieve a successful pregnancy? Would you be willing to undergo an amniocentesis and/or a CVS if the intended parents request this? Would you be willing to undergo A D&C if it is recommended by your clinic or OB? You can elaborate your answers to the above questions here
Would you agree to an induction past 40 weeks of pregnancy if recommended by a physician? Would you be willing to undergo fetal reduction if the intended parents request this? If requested by the intended parents, would you be willing to terminate a pregnancy? Would you be willing to terminate upon the recommendation of OB or MFM? Would you be willing to terminate in the case of very low or no life expectancy? Would you be willing to terminate for severe abnormalities? Would you agree to a late term pregnancy termination if requested by the intended parents and recommended by OB for medical reasons? You can elaborate your answers to the above questions here
Support Systems If you were to be placed on physician ordered bed rest or restricted activities please describe your support system at home and with your children?
Does your partner support your decision to become a gestational surrogate?
Yes No I don't have a partner If no, please explain
How does your partner feel about your desires to become a surrogate?
Getting to know you and fun facts My favorite hobbies or activities are...
Favorite place to go with family and why?
Favorite foods...
Favorite desserts...
Favorite music...
Favorite books or movies...
Favorite flower...
Favorite color...
Do you speak any other languages other than English, and if so what languages?
Getting to know you and fun facts
Communication and travel preferences How much communication do you want with the intended parents during the pregnancy?
How much communication do you want with the intended parents after delivery, if any?
Are you comfortable with the intended parents attending some or all of your surrogacy related medical appointments? If no, please explain
Are you willing to possibly travel out of state to the intended parent’s IVF clinic for the medical screening and embryo transfer? If no, please explain
Have you ever flown on an airplane? Are you comfortable traveling by airplane your screening appointment and embryo transfer? Would you be comfortable with your intended parents in the delivery room for the birth of their baby? If yes, would you like only one or both of the intended parents in the delivery room?
Communication and travel preferences Why do you want to become a surrogate?
What do you think will be the most rewarding part?
What qualities are most important to you in intended parents?
Requested compensation amount
What are your plans for your compensation?
Do you have any questions about being a surrogate or about our program?
How did you hear about NewGen Families?
By submitting this questionnaire, I certify that the information provided on this gestational surrogate application is, to the best of my knowledge, true, accurate, and complete. Your full name:
Date of form completion:
SUBMIT
