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 legal marital status?
 
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13. What is your citizenship status?
 
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If Other, please explain
14. Total number of pregnancies
 
Pregnancy Number Date(s)
Term Delivery:    
Pre-Term Delivery:    
Spontaneous Miscarriage:    
Elective Abortion:    
Stillbirth:    
15. Your pregnancy history
 
Children Own or Surrogacy Date Of Birth Vaginal or C-Section Birth Weight Number of Weeks Carried
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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?
 
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If yes, please explain
20. Pap Smear
 
Pap Smear When was your last Pap? What was the result?
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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?
 
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If Yes, Please Explain
23. Do you smoke?
 
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24. Past or present history of the following:
 
Issues Yes / No Date Stopped Treatment Current Issue? Current Treatment (or n/a)
Asthma:        
Diabetes:        
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:    
Salpingectomy:    
Oophorectomy:    
Other (please specify):    
28. Have you ever been convicted of a felony?
 
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If yes, please explain:
29. Occupation, if employed
 
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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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