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Surrogate Qualifying Questions

Have you had a baby in the past 10 years?

*Are you between the ages of 21-42 years old?

*Do you reside in the United States?

*Are you a U.S. citizen or permanent legal resident (green card holder)?

*Do you currently use recreational drugs?

*Are you a smoker or exposed to secondhand smoke on a regular basis?

Does your household have stable finances that allow you to support yourself and your dependents without relying on surrogate compensation?

*Have you had any of the following pregnancy-related complications or reproductive disorders (select all that apply)?

Pre-eclampsia

Gestational Diabetes (Insulin Controlled)

Placenta Previa

Placental Abruption

Incompetent Cervix

Pre-term Births

Uterine Abnormalities

History of Uterine Rupture

Uterine Prolapse

NONE

*Have you had more than (5) deliveries?

*Have you had 3 or more C-section deliveries?

*Have you been a surrogate before?

*First Name:

*Last Name:

*Email:

*Phone:

*Street Address:

*City:

*State:

*Zip Code:

*Date of Birth:

Sun Mon Tue Wed Thu Fri Sat

Today Clear

*Height:

*Weight:

lbs

When's the best time to contact you?

Weekends Only

Anytime

Additional Comments:

Did someone refer you to our program? If so, please enter their name here: