General Surrogacy Pre-Screening Requirements

First Name

Last Name

Gender

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Do you reside in the United States?

Country

Street Address

Street Address 2

City

State

Zip Code

Phone Number

Email

Are you a U.S. Citizen?

Are you a permanant resident?

Are you between the ages of 21 and 40?

What is your current height?

'

"

What is your current weight?

lbs

Have you given birth to at least one healthy child?

How many vaginal births have you had?

How many c-sections have you had?

How many miscarriages have you had?

How many abortions have you had?

Are you willing to be available for medical clearance, psychological evaluation, background check, and/or drug testing?

Are you currently on government assistance?

What assistance are you receiving?

What is your support system for this journey?

Are all adults in the household willing to undergo a background check, drug test, and psychiatric evaluation?

Are you in good physical and mental health?

Has it been at least six months since your last vaginal or c-section birth?

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