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 need to ascertain whether or not you (or any immediate family members) have Native American heritage. Is anyone in your immediate family affiliated with any tribes or reservations? *

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? *

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)