Find A Surrogate
Be A Surrogate
Find An Egg Donor
Be An Egg Donor
Northeast Assisted Fertility Group
Surrogacy and egg donation
About Us
Mission & Policies
Meet Our Team
Locations
Greenwich, CT
Boston, MA
Washington DC
Miami, FL
Atlanta, GA
Dallas, TX
FAQ
Find A Surrogate FAQ
Be A Surrogate FAQ
Blog
Contact Us
Dallas, TX
11816 Inwood Road
Dallas, TX 75244
Tel: 800-710-1677
Become A Surrogate Questionnaire
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 4
Name
*
First
Middle
Last
Address 1
*
Address 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
Single
Married
Separated
Divorced
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?
Yes
No
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?
Yes
No
What religion do you follow?
Next
Height
*
Current Weight
*
Have you ever been pregnant?
*
Yes
No
Do you have any children?
*
Yes
No
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?
Yes
No
Are you currently taking any medications or do you have any illnesses or conditions?
Yes
No
Please specify medications and/or illnesses/conditions
Do you have regular menstrual periods?
Yes
No
Are you currently using birth control?
Yes
No
Please specify birth control method:
Have you had any sexually transmitted diseases?
Yes
No
Please specify STDs and indicate dates of treatment(s):
Excluding childbirth, please list all hospitalizations and surgeries, including cosmetic surgeries:
Do you smoke?
Yes
No
Please indicate how much:
Do you live in a smoke-free household?
Yes
No
Do you drink alcoholic beverages?
Yes
No
Please indicate how often you drink:
Do you take any recreational drugs?
Yes
No
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?
Yes
No
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?
Yes
No
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?
Yes
No
Would you be willing to travel for medical procedures related to your surrogacy?
Yes
No
Previous
Next
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?
Yes
No
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?
Yes
No
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?
Yes
No
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?
Yes
No
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?
Yes
No
How many siblings do you have?
1
2
3
4 (or more)
Sibling (1)
Is this sibling (1) alive?
Yes
No
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?
Yes
No
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?
Yes
No
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?
Yes
No
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:
Previous
Next
Would you be willing to serve as a surrogate for a family of a different race, religion, or ethnic background from your own?
Yes
No
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?
Yes
No
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.
Submit