Become a Surrogate Form 2 - Fertility SOURCE Companies

Become a Surrogate Form 2

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First Name*

Last Name*

User Name*

Select a username and password:

You will use these credentials to access our database

Password*

Confirm Password*

Phone Number*

Phone Type

Email*

Street 1*

Street 2

City*

State*

Zip Code*

Country

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. .*

Additional Referral Details:

Personal Profile


Date of Birth:

Height:

     

Weight:

Race

Please check ALL that apply. You may check more than one. You will be able to enter more specific ethnic heritage below.

Other:

General Questions


Are you in generally good health?*

Have you ever been told you are infertile?*

Is there a history of infertility in your family?*

Are you currently sexually active?*

Are you currently taking birth control?*

If you are currently taking birth control, were you menstrual cycles regular before starting hormonal birth control?

Are your menstrual periods regular?

Do you ever skip menstrual periods? For example, has there ever been a time where you have had no period during a given month?

Have you ever taken Depo-Provera?*

Are you currently using the Mirena IUD, Skyla IUD, Depo-Provera, Implanon, or Nexplanon?*

Are you currently taking any medications/treatments (including non-prescription)?*

Do you currently smoke cigarettes (either regular smoker, casual smoker or occasional smoker)?*

Have you ever used recreational drugs (i.e. marijuana, cocaine, etc)?*

Have you ever received treatment for drug/alcohol abuse?*

Have any members of your immediate family ever had any issues with drug/alcohol addiction?*

Have any members of your immediate family ever received treatment for drug/alcohol abuse?*

Have you ever received treatment for depression?*

Have any members of your immediate family ever received treatment for depression?*

Have you ever been under the care of a psychiatrist?*

Have you ever had an eating disorder?*

Have you been the victim of rape and/or physical/sexual abuse?*

Are there any known genetic conditions or birth defects in your family?*

Do you have any siblings or ½ siblings with any health issues at all?*

Have you and/or your relatives (parents, grandparents, siblings, children) had any cancer?*

Have you had any hospitalizations and/or surgeries?*

Have you had any tattoos or body piercings within the last twelve months?*

Have you ever been refused as a blood donor?*

Have you ever lived outside of the USA?*

Have you ever been arrested/spent time in jail?*

Have you ever been clinically diagnosed with ADD or ADHD?*

Have you been diagnosed with Anxiety/Panic Disorder, Bipolar Disorder, or Obsessive-Compulsive Disorder?*

Are you adopted?*

Signature


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.

Print Name

Date


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