Welcome to RSMC. Thank you for taking the first step in making a difference! Surrogate mothers are very special. We are very excited to review your initial application. Once submitted, you will be contacted by a Surrogate Specialist who will guide you through the intake process. If you have any questions, please feel free to contact us at 858-436-7184. If it is after hours, please call us at 858-519-2762. We look forward to working with you!
1. First Name
 
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2. Last Name
 
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3. Address
 
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4. City
 
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5. State
 
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6. Zip Code
 
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7. What is your primary phone number?
 
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8. What is your date of birth?
 
   
9. What is your height?
 
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10. What is your weight?
 
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11. What is your ethnicity?
 
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Other / Mixed
12. What is your marital status?
 
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13. Total number of pregnancies
 
Pregnancy Number Date(s)
Term Delivery:    
Pre-Term Delivery:    
Spontaneous Miscarriage:    
Elective Abortion:    
14. Do you have a child/children of your own?
 
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15. What is your citizenship status?
 
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If Other, please explain
16. Your pregnancy history
 
Children Own or Surrogacy Date Of Birth Vaginal or C-Section Birth Weight Number of Weeks Carried
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17. What is your email?
 
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18. Any major complications during pregnancy?
 
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If yes, please explain
19. Pap Smear
 
Pap Smear When was your last Pap? What was the result?
1:    
20. What is your current form of birth control and how long you have been using it
 
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21. Did you experience postpartum depression?
 
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If Yes, Please Explain
22. Do you smoke?
 
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23. Are you currently taking medication for anxiety or depression?
 
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Please Explain
24. Past or present history of the following:
 
Issues Yes / No Date Treatment Medication Dosage
Anemia:          
Asthma:          
Diabetes:          
Gestational Diabetes:          
Heart Problems:          
High Blood Pressure:          
Ovarian Cysts:          
Migraine Headaches:          
Uterine Fibroids:          
Thyroid Problems:          
If yes to any above, please explain.
25. Have you or your partner / spouse ever been diagnosed with
 
STD Myself My Partner Neither
AIDS: Yes Yes Yes
Chlamydia: Yes Yes Yes
Genital Warts: Yes Yes Yes
Gonorrhea: Yes Yes Yes
Hepatitis B: Yes Yes Yes
Hepatitis C: Yes Yes Yes
Herpes: Yes Yes Yes
HIV: Yes Yes Yes
HPV: Yes Yes Yes
Syphilis: Yes Yes Yes
Trichomoniasis: Yes Yes Yes
If yes, when were you diagnosed? Were you treated?
26. Any previous surgeries?
 
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If yes, please explain
27. Have you ever been arrested or convicted of a felony?
 
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If yes, please explain:
28. Current occupational status
 
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29. Multiples
 
Criteria Yes No
Are you willing to carry twins?: Yes Yes
30. How did you hear about our center?
 
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Please Explain
31. What is your email address for communication with you regarding your pre-screen application?
   
32. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
33. Verify your password.
   

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