You’ve taken the first step! Help bring hope of a child to a loving family.
Date of Birth
What are the best times to reach you and at which number:
I understand that as a surrogacy candidate, I must have delivered at least one child of my own that I am currently raising.
I understand that as a surrogacy candidate, the primary requirements for application are that I be a female, between the age of 21-38, a non-smoker, non-drug user and that I am neither significantly overweight nor underweight for my height.
I understand that as a surrogacy candidate, I must live in a stable, non-smoking household, and must possess reliable transportation.
I understand that as a surrogacy candidate, I must not be a recipient of any state or federal financial assistance (welfare).
I understand that as a surrogacy candidate, I would be excluded from the program if I, and/or my partner have been arrested or been in a substance abuse program within the last 10 years.
I understand that as a surrogacy candidate, a full background screen will be conducted on both me and my partner if applicable.
I understand that as a surrogacy candidate, a full female medical examination will be performed to determine my suitability, including an STD screen, drug screen, Hepatitis test and a pelvic ultrasound.
I understand that as a surrogacy candidate, I cannot have had any previous pregnancy complications (bleeding, gestational diabetes, pre term labor).
I understand that as a surrogacy candidate, I must be a United States citizen.
If married, enter your partner’s full legal name:
Being a surrogate requires that you be able to attend many different doctors visits, many with a fertility specialist, who generally work in larger metropolitan areas. Which metropolitan area is closest to you?
If you were referred to The Surrogacy SOURCE by a friend, clinic/doctor or an advertisement, please indicate below. Please provide as much information as possible. For example, If you found us through an advertisement indicate where, or if you were referred by a clinic/doctor provide their name.
Additional Referral Details
Race. Please select ALL that apply:
Please acknowledge that you understand that as a surrogate you must agree to maintain permanent residence in your current state until after delivery of the child/children.
Do you receive any type of public assistance (may include welfare/food stamps/Medical/Medicaid/Cash Aid/State Assistance/etc.)?
If yes, please indicate the assistance you receive below:
I have given birth to a child that I am currently raising in my own home. Please note that this is required in order to become a surrogate.
Are you an experienced surrogate (have you been a surrogate before?)
Are you currently nursing?
Do you have a valid driver’s license, reliable car and car insurance?
Do you and your partner understand that you must abstain from sexual intercourse during the IVF phase of the process (A period of 2-4 weeks)?
Have you been arrested in the last 10 years?
If Yes, describe below:
Has your partner been arrested in the last 10 years?
Do you currently smoke?
Have you or our partner ever been diagnosed with depression, anxiety, bipolar or mood disorders?
Have you ever had an eating disorder?
Do you currently use recreational drugs (i.e. marijuana, cocaine, etc)?
*Please note that you will be drug tested at your medical evaluation.
Have you ever received treatment for drug/alcohol abuse?
Are you a United States citizen?
I enter my full name and today’s date in the fields below as a verification of the information I have provided above.
I certify that all information provided is honest and factual.