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
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?
10. What is your weight?
11. What is your ethnicity?
Other / Mixed
12. What is your legal marital status?
13. What is your citizenship status?
If Other, please explain
14. Total number of pregnancies
Pregnancy Number Date(s)
Term Delivery:    
Pre-Term Delivery:    
Spontaneous Miscarriage:    
Elective Abortion:    
15. Your pregnancy history
Children Own or Surrogacy Date Of Birth Vaginal or C-Section Birth Weight Number of Weeks Carried
16. What is your email?
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17. What is your spouse/partner's first name? (or n/a if no partner/spouse)
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18. What is your spouse/partner's email address? (or n/a)
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19. Any major complications during pregnancy?
If yes, please explain
20. Pap Smear
Pap Smear When was your last Pap? What was the result?
21. What is your current form of birth control and how long you have been using it?
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22. Have you taken any prescribed anti-depression or anti-anxiety medication in the last 12 months?
If Yes, Please Explain
23. Do you smoke?
24. Past or present history of the following:
Issues Yes / No Date Stopped Treatment Current Issue? Current Treatment (or n/a)
Heart Problems:        
High Blood Pressure:        
Ovarian Cysts:        
Migraine Headaches:        
Uterine Fibroids:        
Thyroid Problems:        
If yes to any above, please explain.
25. Are you or your partner / spouse currently diagnosed with:
STD Myself My Partner Neither
AIDS: Yes Yes Yes
Genital Warts: 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. Within the last year, have you or your partner/spouse been diagnosed with the following:
STD Myself My Partner Neither
Chlamydia: Yes Yes Yes
Gonorrhea: Yes Yes Yes
If yes, when were you diagnosed? Were you treated?
27. Any major GYN surgeries involving reproductive organs?
Surgeries Yes/No Date of Procedure (or n/a)
Ovarian Cystectomy:    
Fibroid Removal:    
Other (please specify):    
28. Have you ever been convicted of a felony?
If yes, please explain:
29. Occupation, if employed
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30. How did you hear about our center?
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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