Welcome.

Thank you for considering helping others achieve their dream of parenthood. Are you here because you loved being pregnant? Do you want to help others? The financial compensation for surrogacy is definitely a bonus as well, for many women.

My name is Christie. I am a nurse practitioner and own Forward Fertility, which is based in Madison, WI. I am here to help you navigate this process. Being a surrogate is not for everyone, but exploring the idea if you are interested never hurts. You're not under any obligation by completing the screening application.

Simply answer the questions here and I will give you a call to follow up.

You could be the perfect match for one of the many couples in search of help on their journey to parenthood!

Sincerely,
Christie Olsen
Nurse Practitioner & Founder
Forward Fertility, LLC
Madison, Wisconsin
608-217-7511
Christie@forwardfertility.com
1. What is your first name?
 
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2. How long ago did you first start thinking about being a gestational carrier or gestational surrogate?
 
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Please Explain
3. Do you have medical insurance?
 
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Please explain "other"
4. City
 
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5. State
 
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6. Are you a United States citizen?
 
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7. Are you currently receiving any form of public assistance or medical assistance?
 
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Please described exactly what type of assistance you receive.
8. How flexible is your schedule?
 
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9. What is your current height?
 
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10. What is your current weight?
 
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11. What is your date of birth?
 
   
12. What is your highest level of completed education?
 
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13. Please list any medications (prescription and over the counter) you are currently taking? (enter N/A if you take no medications.)
 
Medications Name of Medication Dosage Reason for taking medication
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14. Please indicate the total number of times you have been pregnant (include all pregnancies)?
 
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15. Please indicate any complications you have had with any of your previous pregnancies (Select all that apply to you).
 




























If you selected any box above, please provide details about that selection HERE:
16. Please indicate how many miscarriages you have had and provide information about each one of them.
 
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Please indicate the year of the miscarraige, how far along you were, and any complications.
17. How many abortions have you had?
 
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Please indicate what year, how far along you were, and if there were any complications.
18. Do you have or have had high blood pressure?
 
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If yes, please explain.
19. Do you have or have you ever had seizures?
 
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If yes, please explain.
20. How would you rate your own physical health?
 
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Please Explain
21. Have you ever undergone any fertility treatments (medications, insemination, IVF, acupuncture, etc.) to become pregnant?
 
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Please explain.
22. Have you ever been evaluated for or diagnosed with Endometriosis?
 
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Please include when this occurred, with which doctor, and if you had any trouble conceiving a pregnancy.
23. How many days per week do you use tobacco in any form?
 
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24. Have you ever had an endometrial ablation or hysterectomy?
 
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Please Explain
25. Are you around anyone who smokes cigarettes?
 
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If your are around someone who smokes, please describe how often and in what situations?
26. When is the last time you have used recreational or illicit drugs (cocaine, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)?
 
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Please explain which drugs, how often, and any additional information.
27. When is the last time you had marijuana?
 
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28. How many days per week do you drink alcoholic beverages?
 
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Please Explain
29. Have you ever been arrested, including a DUI arrest?
 
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Please Explain
30. Have you ever placed a child up for adoption (not including a child born via gestational surrogacy)?
 
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Please Explain
31. Do you have any children who are not currently living with you full time?
 
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Please explain here.
32. Do you have or have had depression (including post-partum, chronic, or situational)?
 
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If yes, please explain.
33. Have you ever been hospitalized for psychiatric care?
 
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Please Explain
34. Do you now have or have you EVER had eating disorders?
 
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If yes, please explain.
35. Have you ever been diagnosed or treated for any emotional disorder?
 
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If yes, please explain.
36. Have you ever been convicted of a crime?
 
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Please Explain
37. What questions do you have about being a gestational surrogate?
 
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Please list questions here:
38. Where did you hear abour Forward Fertility, LLC?
 














Please share how Forward Fertility found you!
39. Is this the first time you have applied to be a gestational surrogate?
 
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40. What, if anything, concerns you about being a gestational carrier? (select all that apply to you)
 










Please share any additional thoughts about your concerns.
41. By selecting "Agree", you are stating that you will and you have answered all questions to the best of your ability, without purposeful omission or deception. You understand being a gestational surrogate is a serious responsibility and a process that requires maturity, excellent communication, honesty, and a willingness to help others.
 
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Please list any questions you have about this.
42. By selecting “Agree”, you understand the following: Some of the questions in this application are very personal. No answers will be shared with anyone outside of Forward Fertility, LLC without your permission. Certain questions and answers are not shared with recipients and are only used for our internal purposes.
 
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Please list any questions you have about this.
43. By selecting "Agree", you are stating that you understand the treatment involves a psychological evaluation, medical testing, a legal contract drafted by an attorney, and frequent visits to a fertility center. You may need to administer injections to yourself daily, for a period of weeks. You will also undergo blood draws and vaginal ultrasounds at the fertility clinic. Becoming pregnant as a gestational surrogate is not a simple process.
 
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Please list any questions you have about this.
44. By selecting “Agree” you are stating you understand that in a gestational surrogacy process, you are NOT genetically related to the child or children you are carrying. The egg and sperm source are from other people; not you. You also understand the egg and sperm source will be tested according to FDA guidelines to reduce your risk of communicable diseases.
 
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Please list any questions you have about this.
45. What is the primary phone number you would like us to use to contact you?
 
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46. What is your email address for communication with you regarding your pre-screen application?
   
47. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
48. Verify your password.
   

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