IVF Does Not Raise Breast Cancer Risk

Name *

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If you are currently employed, please indicate start date of current job and provide a brief history of your past employment

If you are currently unemployed, how are you financially supported?

Do you have health insurance?

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Health insurance is not required to be a surrogate

Please tell us how you heard of our program, and why you are interested in being a surrogate.

Have you informed your spouse, children, other family members, etc. of your interest in becoming a surrogate? If so, are they supportive?

Do you follow any particular religion?

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Height *

Current Weight *

Have you ever been pregnant? *

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Are your children currently living with you?

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Are you currently taking any medications or do you have any illnesses or conditions?

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Have you had any sexually transmitted diseases?

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Excluding childbirth, please list all hospitalizations and surgeries, including cosmetic surgeries:

Do you smoke?

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Do you take any recreational drugs?

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How many sexual partners have you had in the past six months?

Have you been a surrogate or egg donor before?

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Please describe, to the best of your ability, your ethnic background:

Have you ever been arrested or convicted of a crime?

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Please describe the level of your education and degree dates:

Do you plan on having any more children of your own?

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Would you be willing to travel for medical procedures related to your surrogacy?

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Mother

Please let us know if there is any history of cancer, diabetes, mental illness, birth defects, heart disease, or any other conditions in your family.

Is your mother living?

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No
Don't know

Father

Is your father living?

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Don't know

Children

Siblings

Do you have or have you had any siblings?

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Would you be willing to serve as a surrogate for a family of a different race, religion, or ethnic background from your own?

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Would you be willing to serve as a surrogate for an unmarried couple as well as a married couple? Single parent or same sex parents?

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Please specify any preference you may have:

Please read and agree to the following. *

I verify that the information on this application is complete and accurate. I understand that any false statement made by me may be viewed as perjury and in violation of the penal laws of my state and may subject me to criminal and/or civil penalties.

I.V.F. Does Not Raise Breast Cancer Risk, Study Shows

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