Northeast Assisted Fertility Group Location in Dallas, Texas

Name *

First

Middle

Last

Address 1 *

Address 2

City *

State *

Zip *

Email *

Home Phone *

Cell Phone

Work Phone

What number is best to reach you at?

Home
Cell
Work

At which numbers may we leave a message for you?

Home
Cell
Work

Date of Birth *

Occupation

Marital Status

Spouse/Partner's name (if any)

Length of relationship

Spouse/Partner's occupation

Spouse/Partner's date of birth

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?

Health insurance is not required to be a surrogate

Please state your insurance carrier and policy name

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?

What religion do you follow?

Height *

Current Weight *

Have you ever been pregnant? *

Do you have any children? *

Please list the birthdates of your children and indicate the date(s) of any miscarriages or terminations. *

Please specify whether vaginal or c-section delivery.

Are your children currently living with you?

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

Please specify medications and/or illnesses/conditions

Do you have regular menstrual periods?

Are you currently using birth control?

Please specify birth control method:

Have you had any sexually transmitted diseases?

Please specify STDs and indicate dates of treatment(s):

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

Do you smoke?

Please indicate how much:

Do you live in a smoke-free household?

Do you drink alcoholic beverages?

Please indicate how often you drink:

Do you take any recreational drugs?

Please indicate what kind of recreational drugs and how often:

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

Have you been a surrogate or egg donor before?

Please specify surrogate and/or egg donor and provide dates:

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

Have you ever been arrested or convicted of a crime?

Please provide what crime and provide dates:

Please describe the level of your education and degree dates:

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

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

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?

Yes
No
Don't know

Current age of mother

Age at death

Does your mother have any illnesses? If so, which?

Illnesses during lifetime and cause of death

Father

Is your father living?

Yes
No
Don't know

Current age of father

Age at death

Does your father have any illnesses? If so, which?

Illnesses during lifetime and cause of death:

Children

How many children do you or have you had?

1
2
3
4 (or more)

Child (1)

Is this child (1) alive?

Current age of child (1)

Age at death of child (1)

Does this child (1) have any illnesses? If so, which?

Illnesses during lifetime and cause of death:

Child (2)

Is this child (2) alive?

Current age of child (2)

Age at death of child (2)

Does this child (2) have any illnesses? If so, which?

Illnesses during lifetime and cause of death:

Child (3)

Is this child (3) alive?

Current age of child (3)

Age at death of child (3)

Does this child (3) have any illnesses? If so, which?

Illnesses during lifetime and cause of death:

Child (4)

Is this child (4) alive?

Current age of child (4)

Age at death of child (4)

Does this child (4) have any illnesses? If so, which?

Illnesses during lifetime and cause of death:

Siblings

Do you have or have you had any siblings?

How many siblings do you have?

1
2
3
4 (or more)

Sibling (1)

Is this sibling (1) alive?

Current age of sibling (1)

Age at death of sibling (1)

Does this sibling (1) have any illnesses? If so, which?

Illnesses during lifetime and cause of death:

Sibling (2)

Is this sibling (2) alive?

Current age of sibling (2)

Age at death of sibling (2)

Does this sibling (2) have any illnesses? If so, which?

Illnesses during lifetime and cause of death:

Sibling (3)

Is this sibling (3) alive?

Current age of sibling (3)

Age at death of sibling (3)

Does this sibling (3) have any illnesses? If so, which?

Illnesses during lifetime and cause of death:

Sibling (4)

Is this sibling (4) alive?

Current age of sibling (4)

Age at death of sibling (4)

Does this sibling (4) have any illnesses? If so, which?

Illnesses during lifetime and cause of death:

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

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?

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.

Dallas, TX