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Eligibility Application

1Intake Form

First Name

Last Name

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Today Clear

Phone Number

State of Residence

Height

Weight

lbs

Annual Combined Household Income

Do you have at least one child of your own that you are currently raising?

Yes

Do you currently smoke, vape, use tobacco, or any nicotine products?

Yes

Do you currently use drugs?

Yes

Please explain if currently use drugs

Please select all state benefits or assistance that you receive.

None

State-subsidized Medical Insurance

Public Housing/Section 8

WIC/Food Stamps

Other

Welfare/Cash Assistance

Please explain if other.

Do you or any adult in your household have a criminal record?

Yes

Please explain. Include the year and charge.

How did you hear about us?

Personal Referral

Instagram

Facebook

Internet Search

Other

We would love to hear who referred you!

If other, please specify.

Are you currently taking prescription medication?

Yes

Please list medication, dosage, and treatment purpose.

Do you have any current medical conditions?

Yes

Please list any current medical conditions.

How many pregnancies have you had?

How many live births have you had?

How many C-sections have you had?

4 or more

Have you experienced gestational diabetes or preeclampsia?

Gestational Diabetes - Diet-Controlled

Gestational Diabetes - Medicated

Preeclampsia

None of the Above

Have any of your live births occurred before 37 weeks gestation?

Yes

Which pregnancy, what was the gestational age at birth, and was a reason determined for the premature delivery?

Has anything abnormal occurred during any pregnancy, delivery, or postnatal recovery period?

Yes

Please describe any abnormal occurrences in detail.

What types of intended parents are you open to helping? (Check all that apply)

Male/Female Couple

Gay Couple

Single Parent

Undecided

Any

Multiple Pregnancy Views (Please note all CS parents transfer only ONE embryo per transfer)

What are your preferences if a fetal malformation is detected? (Please note many parents wish to be able to make this decision themselves.)

What is more important to you in selecting a surrogacy agency?

Timeline

Benefit Package

Safeguards

Expertise

Personalized Support

Match Process

What is your preferred next step(s)?

Begin screening paperwork

Learn more about the surrogacy process

Learn more about our agency

Book an educational call with one of our experienced surrogates

None at this time, I am just curious about my eligibility

What is your preferred methods of communication?

Phone

Text

Do you have any questions for us?