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Gestational Carrier Initial Inquiry

1Personal Information
2Additional Questions

First Name

Last Name

Country

State of Residence

Phone Number

Is this a mobile number?

Yes

If yes, can text messages be sent regarding your application?

Yes

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Today Clear

Enter your height:

Enter your approximate weight (lbs):

lbs

Have you been pregnant before?

Yes

If you are over the age of 37, have you had a pregnancy within the last 5 years?

Yes

Does not apply

Have you had a baby in the last 12 months?

Yes

How many vaginal deliveries have you had?

How many C-section deliveries have you had?

In your most recent pregnancy, select any complications you had, if any:

Miscarriage

Gestational Diabetes

Pre-eclampsia/high blood pressure

Placenta Previa

Early Term Labor (before 36 weeks)

Bed rest for more than 14 days

Pre or Post-partum hemorrhaging

Post-partum depression

Other

I did not have any complications in my last pregnancy

If Other, please explain:

Have you ever been a surrogate/gestational carrier before?

Yes

Do you suffer from any of the following menstrual disorders?

Uterine Fibroids

Clotting Disorders

Endometriosis

Polycystic Ovarian Syndrome (PCOS)

Other

None of the above

If Other, please explain:

Do you have a history of any Sexually Transmitted Diseases/Infections within the last 12 months?

Yes

If "yes", please explain when:

Have you given any of your children up for adoption?

Yes

If "Yes", please explain when and why:

Have you had any other children that you did not give up for adoption?

Yes

Have you had any children removed from your home by a government agency?

Yes

If "Yes", please explain:

Do you have legal custody of all of your children that live with you?

Yes

If no, please explain:

Please select all forms of government assistance you receive:

Medicaid and/or CHIP (for self or family)

Supplemental Nutrition Assistance Program (SNAP-food stamps)

Section 8 Housing Assistance (HUD program)

TANF

WIC

I do not receive any government assistance.

Other

If Other, please specify:

Have you been arrested in the last 5 years?

Yes

If "Yes", please explain:

Are you on probation?

Yes

Are you a U.S. citizen or legal resident?

Yes

Are you currently going through divorce proceedings?

Yes

Are you currently taking any medication for depression or anxiety?

Yes

Do you use tobacco, vape, hookah or nicotine patches?

Yes

Do you use marijuana?

Yes

Do you use illegal drugs?

Yes

Do you have a passport?

Passport Expiration Date

Would you be willing to travel internationally?

I can commit to staying in the state I am currently living for at least 24 months.

Yes