Surrogacy Application Step 1 of 9 11% By checking this box, you acknowledge the importance of honest and complete answers to the questions asked. We use the application to complete the screening process and find the best match options for you.* I agree & acknowledge. Basic InformationName* First Last Phone*Email* Location* City State / Province / Region Date of birth:* Month Day Year AgeHeight* Weight* Ethnicity* American Indian/Alaskan Native Asian Black/African American Hispanic/Latina Hawaiian/Other Pacific Islander White Not Listed Marital Status* Married Engaged Relationship (cohabitating) Relationship (living separately) Single Divorced Legally Separated Occupation* Are you currently working with anyone from Los Angeles Surrogacy?* No Yes Who are you working with? How did you originally hear about Los Angeles Surrogacy?* Number of Previous C-section(s)*Number of Previous Vaginal Births*Birth Control Method* Are You a Repeat Surrogate?* No Yes Are You a US Citizen?* No Yes Immigration Status Permanent Citizen/Green Card Holder Temporary Citizen/Visa Holder Not a Citizen/No Green Card Do you fully understand the commitment and responsibilities being a surrogate entails?* No Yes Religious Affiliation If you are a repeat surrogate, please list your surrogacy cycle detailsHow long have you been considering becoming a surrogate mother? Please describe your reasons for wanting to become a surrogate mother?Are you willing to be a surrogate mother for a single parent?* No Yes Are you willing to be a surrogate mother for a gay couple?* No Yes For additional compensation, would you be willing to be a surrogate mother for a HIV positive couple if the HIV was not passed down to you?* No Yes Are you willing to carry twins?* No Yes If you are willing to carry twins, please note twin pregnancies are considered higher risk pregnancies than carrying one baby. There are greater chances of bedrest and premature labor. Please acknowledge that you are willing to carry twins I don't understand I understand If you prefer not to carry twins, there is less than a 5% change the single embryo could split naturally. If it did, would you be willing to carry both babies? No Yes Are you willing to speak with the intended parent(s) by Skype or WeChat prior to matching? No Yes Employment and BackgroundEmployer What’s your hourly rate? Who is the primary source of income in your home? What is your educational background? Are you currently receiving government benefits?* No Yes If so, which benefits are you receiving? Have you ever been arrested?* No Yes If yes, what crime were you charged with and when?Are you willing to consent to a background check?* No Yes RelationshipsRegardless of relationship status, are you currently legally married?* No Yes If you are not married, do you plan on becoming married during your surrogacy journey? No Yes What is your partner’s first name Partners date of birth MM slash DD slash YYYY Partners Ethnicity American Indian/Alaskan Native Asian Black/African American Hispanic/Latina Hawaiian/Other Pacific Islander White What is your partner’s educational background Your partner will be required to have a blood test, the test will screen for infectious diseases and drug use. Is your partner willing to do this? (non-negotiable) Yes No Describe the type of work that your partner does How long have you been in a relationship with your partner? Is your partner in good health? Yes No Has your partner ever been arrested? Yes No If your partner has been arrested what was the charge?Your partner may be asked to consent to a background check. Would you partner be willing to do this? Yes No List those that currently reside in your household Do you or your partner smoke cigarettes or use any nicotine products?* Yes No If yes to the above, please list who and what products they use.How often do your children go to the doctor? What kind of relationship would you like to have with the intended parents?Please list the first names of family, friends, coworkers and children who will support you during your surrogacy process* Have you ever given a child up for adoption? Yes No Please provide details of the adoption. Prior PregnanciesHow many times have you been pregnant?*012345 or moreHave you had any miscarriages and/or terminations?* Yes No Please provide details of any miscarriages and/or terminations.Was your birth(s) vaginal or C-section?* Vaginal C-section Mixture Weeks at conclusion of each pregnancy* Complications during any pregnancy* Did you have any trouble getting pregnant?* Yes No Did you have morning sickness during any of your pregnancies?* Yes No Did you have any food cravings during any of your pregnancies?* Yes No Are you currently breastfeeding?* Yes No Did you develop Gestational Diabetes during any your pregnancies?* Yes No Did you have pre-eclampsia during any of your pregnancies?* Yes No Child’s First Name(s) Birth Date(s) Birth Weight(s) Length of children at birth Health of ChildrenDo you have a family history of fertility problems? (describe)* Health and FitnessWhat vitamins and nutritional supplements are you currently taking?* List any medications you have taken within the past 12 months* How often do you go to the doctor?* How many days does your period bleed last?* How often do you drink alcoholic beverages?* Do you smoke cigarettes, use any nicotine products or use recreational drugs including marijuana?* No Yes If yes, please provide details of any nicotine or recreational drug use.Please acknowledge that at the time of medical screening and potentially throughout the process, you will be screened for nicotine and marijuana use. Please acknowledge you are ok with this and will pass these tests during your surrogacy journey* I acknowledge I decline Do you have any current or past health concerns (describe)* Do you have any history of high blood pressure?* No Yes Have you ever been hospitalized other than giving birth? (describe)*Have you ever been in therapy or counseling? (describe reason)* When was your last pap smear?* What were your pap smear results?* Have you ever had an irregular pap smear?* No Yes Do you have any allergies? (describe)* Describe your diet*Do you typically cook at home or eat out?* Cook at home Eat out How often do you eat out?* Do you currently exercise or work out? If Yes please describe your current exercise routine.* Do you work out or exercise while pregnant? If so, what is your preferred form of prenatal exercise?* LifestyleDescribe your lifestyle and typical day-to-day activities*What activities do you enjoy for fun and recreation?*What do you do to relax?*Do you have any collections?What was your favorite vacation?Describe the home you live in and your neighborhoodIs there anything you would like to add about yourself for Intended Parents? Insurance InformationDo you currently have medical (health) insurance?* No Yes If you have medical (health) insurance, what is the name of your insurance company?* Is your medical (health) insurance through your employer, individual policy or the State?Choose oneEmployerIndividual PolicyState PolicyDo you currently have an active driver’s license?* No Yes Do you have a car?* No Yes Are you willing to come to the Los Angeles area for your OBGYN screening and preparation? (travel expenses will be reimbursed)* No Yes OtherIf bed rest is prescribed during pregnancy, will you require childcare assistance?* No Yes Would you be willing to terminate pregnancy if medically advised?* No Yes If the fetus is diagnosed with a fatal or debilitating disease, would you be willing to terminate the pregnancy if requested by the intended parents?* No Yes If not immune to certain illnesses that could negatively impact the pregnancy for both you and baby, would you be willing to receive needed vaccines if required by the fertility doctor?* No Yes If the fetus were diagnosed with Down syndrome (Trisomy 21), would you be willing to terminate the pregnancy if requested by the intended parents?* No Yes If you were to become pregnant with more than triplets (3), would you be willing to reduce the number of embryos within the first trimester if requested by the Intended Parents?* No Yes Please write at least a one paragraph biography about yourself and your family. The intend-ed parents will read this, they want to know a little about you and who you are. This is your chance to for the parents to know why they should choose you to be their surrogate mother.*Please attached photos of yourself along with your family. (Please include family oriented photos. It’s ok to include selfies but please also include a photo or two that are not selfies)Maximum of 4 photos (max file size - 2MB) ) By uploading your pictures here, you are giving Los Angeles Surrogacy permission to use these images Drop files here or Select files Accepted file types: jpg, jpeg, png, Max. file size: 2 MB, Max. files: 4. CommentsThis field is for validation purposes and should be left unchanged. Need help or have questions about the application? Get in touch with us and we'll help you through the process.
