Welcome to Physician's Surrogacy. Thank you for taking the first step in making a difference! Surrogate mothers are very special. We are very excited to review your initial application. Once submitted, you will be contacted by a Surrogate Specialist who will guide you through the intake process. If you have any questions, please feel free to contact us at 858-299-4540.

1.

First Name *

2.

Last Name *

3.

Address *

4.

City *

5.

State *

6.

Zip Code *

7.

What is your primary phone number? *

8.

What is your height? *

9.

What is your weight? *

10.

What is your ethnic heritage? (Check all that apply) *

11.

Due to tribal laws (we're required to ask), are you or an immediate family member a member of a Native American or Alaskan Indian tribe? *

12.

Do you have a valid drivers license? *

13.

Do you have reliable transportation? *

14.

Are you currently in a relationship? *

15.

What is your legal marital status? *

16.

What is your citizenship status? *

17.

What is your spouse/partner's name? (or n/a if no partner/spouse) *

18.

What is your email? *

19.

What is your spouse/partner's email address? (or n/a) *

20.

How many biological children do you have? *

21.

Total number of pregnancies *

22.

Have you ever had an abortion? *

23.

Have you experienced a spontaneous miscarriage? *

24.

Occupation, if employed *

25.

Please select the most accurate answer in regards to your pregnancies: *

26.

Have you ever had any of the following major complications during pregnancy? *

27.

When was your most recent delivery? *

28.

Your delivery history

  Own or Surrogacy Date Of Birth Vaginal or C-Section Birth Weight Number of Weeks Carried
1
2
3
4
5
6
7
8

29.

Are you currently breastfeeding? *

30.

What is your current form of birth control? *

31.

Have you ever had endometrial ablation? *

32.

Have you ever used long-acting birth control? *

  Date inserted Date removed
IUD (Mirena/ Skyla /Liletta)
IUD - Copper (Paraguard)
Depo-Provera (Depo Shot)
Arm Implant (Implanon /Nexplanon)

33.

Have you taken any prescribed anti-depression or anti-anxiety medication in the last 12 months? *

34.

Do you smoke? *

35.

How frequently do you drink alcoholic beverages? *

36.

Have you ever had any of the following health issues? *

37.

Any major GYN surgeries involving reproductive organs? *

38.

Have you had symptoms of migraine headaches during pregnancy that required treatment? *

39.

Have you had asthmatic symptoms during pregnancy that required treatment? *

40.

Have you ever taken medication for gestational diabetes? *

41.

Are you or your partner / spouse currently diagnosed with: *

42.

Within the last year, have you or your partner/spouse been diagnosed with the following: *

43.

Have you ever been convicted of a felony? *

44.

Has your partner/spouse ever been convicted of a felony? *

45.

How did you hear about our center? *

46.

What is your date of birth? *


What is your email address for communication with you regarding your pre-screen application?
(6-20 characters with 4 or more letters and 1 or more numbers)
(Must match)