Physicians Surrogacy - Gestational Carrier
Welcome to Physician's Surrogacy. 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 858-299-4540.
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 height?
 
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9. What is your weight?
 
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10. What is your ethnic heritage? (Check all that apply)
 











Other:
11. Due to tribal laws, we need to ascertain whether or not you (or any immediate family members) have Native American heritage. Is anyone in your immediate family affiliated with any tribes or reservations?
 
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12. Do you have a valid drivers license?
 
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13. Do you have reliable transportation?
 
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14. Are you currently in a relationship?
 
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15. What is your legal marital status?
 
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16. What is your citizenship status?
 
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If Other, please explain
17. What is your spouse/partner's name? (or n/a if no partner/spouse)
 
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18. What is your email?
 
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19. What is your spouse/partner's email address? (or n/a)
 
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20. How many biological children do you have?
 
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Please Explain
21. Total number of pregnancies
 
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22. Have you ever had an abortion?
 
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if so, list dates
23. Have you experienced a spontaneous miscarriage?
 
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If so, list dates.
24. Occupation, if employed
 
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25. Please select the most accurate answer in regards to your pregnancies:
 
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Please Explain
26. Have you ever had any of the following major complications during pregnancy?
 
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If yes, please explain
27. When was your most recent delivery?
 
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28. Your delivery history
 
Delivery Own or Surrogacy Date Of Birth Vaginal or C-Section Birth Weight Number of Weeks Carried
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29. Are you currently breastfeeding?
 
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Please Explain
30. What is your current form of birth control?
 
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How long have you been using this method? Please explain.
31. Have you ever had endometrial ablation?
 

32. Have you ever used long-acting birth control?
 



If yes, please list dates
33. Have you taken any prescribed anti-depression or anti-anxiety medication in the last 12 months?
 
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If yes, which medication? Please explain
34. Do you smoke?
 
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If yes, how often?
35. How frequently do you drink alcoholic beverages?
 
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Will you be able to abstain from alcohol throughout your surrogacy journey?
36. Have you ever had any of the following health issues?
 






If yes to any above, please explain.
37. Any major GYN surgeries involving reproductive organs?
 





If yes, please provide dates
38. Have you had symptoms of migraine headaches during pregnancy that required treatment?
 
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Please Explain
39. Have you had asthmatic symptoms during pregnancy that required treatment?
 
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Please Explain
40. Have you ever taken medication for gestational diabetes?
 
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Please Explain
41. Are you or your partner / spouse currently diagnosed with:
 







42. Within the last year, have you or your partner/spouse been diagnosed with the following:
 




If yes, when were you diagnosed? When were you treated?
43. Have you ever been convicted of a felony?
 
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If yes, please explain:
44. Has your partner/spouse ever been convicted of a felony?
 
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Please Explain
45. How did you hear about our center?
 
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Please Explain
46. What is your date of birth?
 
   
47. What is your email address for communication with you regarding your pre-screen application?
   
47. Please verify your email address
   
48. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
49. Verify your password