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
 
250 characters remaining "" 
2. Last Name
 
250 characters remaining "" 
3. Address
 
250 characters remaining "" 
4. City
 
250 characters remaining "" 
5. State
 
"" 
6. What is your primary phone number?
 
250 characters remaining "" 
7. What is your height?
 
"" 
8. What is your weight?
 
"" 
9. What is your ethnic heritage? (Check all that apply)
 
Ethnicity Mother's Side Father's Side
Asian: Yes Yes
Black or African American: Yes Yes
Hispanic or Latino: Yes Yes
Native American: Yes Yes
German: Yes Yes
French: Yes Yes
Irish: Yes Yes
Italian: Yes Yes
Pacific Islander: Yes Yes
Cherokee: Yes Yes
Caucasian: Yes Yes
Other: Yes Yes
Other / Mixed
10. 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?
 
"" 
11. Do you have a valid drivers license?
 
"" 
12. Do you have reliable transportation?
 
"" 
13. Are you currently in a relationship?
 
"" 
14. What is your legal marital status?
 
"" 
15. What is your citizenship status?
 
"" 
If Other, please explain
16. What is your spouse/partner's name? (or n/a if no partner/spouse)
 
250 characters remaining "" 
17. What is your email?
 
250 characters remaining "" 
18. What is your spouse/partner's email address? (or n/a)
 
250 characters remaining "" 
19. How many biological children do you have?
 
"" 
Please Explain
20. Total number of pregnancies
 
Pregnancy Description Number Date(s)
Term Delivery:    
Pre-Term Delivery:    
Spontaneous Miscarriage:    
Elective Abortion:    
Stillbirth:    
21. How many C-sections have you had?
 
"" 
22. Occupation, if employed
 
250 characters remaining "" 
23. Please select the most accurate answer in regards to your pregnancies:
 
"" 
Please Explain
24. Have you ever had any of the following major complications during pregnancy?
 
"" 
If yes, please explain
25. When was your most recent delivery?
 
"" 
26. Your delivery history
 
Delivery Own or Surrogacy Date Of Birth Vaginal or C-Section Birth Weight Number of Weeks Carried
1:          
2:          
3:          
4:          
5:          
6:          
7:          
8:          
27. Are you currently breastfeeding?
 
"" 
Please Explain
28. What is your current form of birth control?
 
"" 
How long have you been using this method? Please explain.
29. Have you ever had endometrial ablation?
 
"" 
30. Past History of long-acting birth control:
 
LARC When Started When Stopped
Depo-Provera Shot:    
IUD (Mirena / Skyla / Liletta):    
Nexplanon / Implanon:    
31. Have you taken any prescribed anti-depression or anti-anxiety medication in the last 12 months?
 
"" 
If yes, which medication? Please explain
32. Do you smoke?
 
"" 
If yes, how often?
33. How frequently do you drink alcoholic beverages?
 
250 characters remaining "" 
Will you be able to abstain from alcohol throughout your surrogacy journey?
34. Past or present history of the following:
 
Issues Yes / No Date Stopped Treatment Current Issue? Current Treatment (or n/a)
Diabetes:        
Heart Problems:        
High Blood Pressure:        
Ovarian Cysts:        
Uterine Fibroids:        
Thyroid Problems:        
If yes to any above, please explain.
35. 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):    
36. Have you had symptoms of migraine headaches during pregnancy that required treatment?
 
"" 
Please Explain
37. Have you had asthmatic symptoms during pregnancy that required treatment?
 
"" 
Please Explain
38. Have you ever taken medication for gestational diabetes?
 
"" 
Please Explain
39. Are you or your partner / spouse currently diagnosed with:
 
Type of 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?
40. 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?
41. Have you ever been convicted of a felony?
 
"" 
If yes, please explain:
42. Has your partner/spouse ever been convicted of a felony?
 
"" 
Please Explain
43. How did you hear about our center?
 
"" 
Please Explain
44. What is your date of birth?
 
   
45. Zip Code
 
250 characters remaining "" 
46. What is your email address for communication with you regarding your pre-screen application?
   
46. Please verify your email address
   
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