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:* MM DD YYYY AgeHeight*Weight*Ethnicity*American Indian/Alaskan NativeAsianBlack/African AmericanHispanic/LatinaHawaiian/Other Pacific IslanderWhiteNot ListedMarital Status*MarriedEngagedRelationship (cohabilitating)Relationship (living separately)SingleDivorcedLegally SeparatedOccupation*Are you currently working with anyone from Los Angeles Surrogacy?*NoYesWho 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?*NoYesAre You a US Citizen?*NoYesImmigration StatusPermanent Citizen/Green Card HolderTemporary Citizen/Visa HolderNot a Citizen/No Green CardDo you fully understand the commitment and responsibilities being a surrogate entails?*NoYesReligious AffiliationIf 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?*NoYesAre you willing to be a surrogate mother for a gay couple?*NoYesFor 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?*NoYesAre you willing to carry twins?*NoYesIf 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 twinsI don't understandI understandIf 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?NoYesAre you willing to speak with the intended parent(s) by Skype or WeChat prior to matching?NoYes Employment and BackgroundEmployerWhat’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?*NoYesIf so, which benefits are you receiving?Have you ever been arrested?*NoYesIf yes, what crime were you charged with and when?Are you willing to consent to a background check?*NoYes RelationshipsRegardless of relationship status, are you currently legally married?*NoYesIf you are not married, do you plan on becoming married during your surrogacy journey?NoYesWhat is your partner’s first namePartners date of birth Date Format: MM slash DD slash YYYY Partners EthnicityAmerican Indian/Alaskan NativeAsianBlack/African AmericanHispanic/LatinaHawaiian/Other Pacific IslanderWhiteWhat is your partner’s educational backgroundYour 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)YesNoDescribe the type of work that your partner doesHow long have you been in a relationship with your partner?Is your partner in good health?YesNoHas your partner ever been arrested?YesNoIf 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?YesNoList those that currently reside in your householdDo you or your partner smoke cigarettes or use any nicotine products?*YesNoIf 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?YesNoPlease provide details of the adoption. Prior PregnanciesHow many times have you been pregnant?*012345 or moreHave you had any miscarriages and/or terminations?*YesNoPlease provide details of any miscarriages and/or terminations.Was your birth(s) vaginal or C-section?*VaginalC-sectionMixtureWeeks at conclusion of each pregnancy*Complications during any pregnancy*Did you have any trouble getting pregnant?*YesNoDid you have morning sickness during any of your pregnancies?*YesNoDid you have any food cravings during any of your pregnancies?*YesNoAre you currently breastfeeding?*YesNoDid you develop Gestational Diabetes during any your pregnancies?*YesNoDid you have pre-eclampsia during any of your pregnancies?*YesNoChild’s First Name(s)Birth Date(s)Birth Weight(s)Length of children at birthHealth 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?*NoYesIf 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 acknowledgeI declineDo you have any current or past health concerns (describe)*Do you have any history of high blood pressure?*NoYesHave 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?*NoYesDo you have any allergies? (describe)*Describe your diet*Do you typically cook at home or eat out?*Cook at homeEat outHow 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?*NoYesIf 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?*NoYesDo you have a car?*NoYesAre you willing to come to the Los Angeles area for your OBGYN screening and preparation? (travel expenses will be reimbursed)*NoYes OtherIf bed rest is prescribed during pregnancy, will you require childcare assistance?*NoYesWould you be willing to terminate pregnancy if medically advised?*NoYesIf the fetus is diagnosed with a fatal or debilitating disease, would you be willing to terminate the pregnancy if requested by the intended parents?*NoYesIf 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?*NoYesIf the fetus were diagnosed with Down syndrome (Trisomy 21), would you be willing to terminate the pregnancy if requested by the intended parents?*NoYesIf 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?*NoYesPlease 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 Accepted file types: jpg, jpeg, png. NameThis 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.
