3 Sisters Surrogacy
THANK YOU FOR YOUR INTEREST IN 3 SISTERS SURROGACY. With our new higher compensation and support structure, we are here for YOU, every step of the way. Please fill out the Initial Application to get the process started!
 

1. I attest that I am not working as an employee or agent of another surrogacy agency either as a paid employee or contractor.
 
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2. Please provide us with your email address
 
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3. First name
 
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4. Last Name
 
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5. What is your primary phone number?
 
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6. What is your street address?
 
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7. What is your city?
 
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8. What is your state?
 
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9. What is your zip code?
 
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10. What is your marital status?
 
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11. Do you have health insurance that does not exclude gestational surrogacy (TriCare will not cover. Please consult your plan manager and ask "Will you cover my maternity benefits if I am acting as a gestational surrogate"?
 
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12. What is the name of your health insurance carrier?
 
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13. How much compensation are you requesting? ($30K w/no insurance is about average; $32K-$40K for 2nd time and/or insurance)
 
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14. What is your husband's name (if applicable)
 
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15. What is your husband or partners occupation and date of birth and phone #.
 
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16. What is your husband's email address (if applicable)
 
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17. Are you currently available for surrogacy?
 
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18. Do you receive any type of Government assistance, such as Medicaid, Section 8, Food Stamps, WIC?
 
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Please Explain
19. Would you be comfortable with a gay family?
 
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20. Would you be willing to terminate a pregnancy for medical necessity?
 
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21. Are you a US Citizen or legal resident?
 
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22. Next of kin phone number (not spouse/partner)
 
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23. Secondary phone and email of friend/relative
 
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24. What is your frame size?
 
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25. What race would you most likely be affiliated?
 
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26. What is your date of birth?
 
   
27. What is your height?
 
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28. What is your weight in pounds?
 
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29. What is your blood type?
 
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30. Have you had Chicken Pox or received the vaccine?
 
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Please Explain
31. How old were you when you had your first period?
 
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32. Have you had pre-term labor?
 
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Please Explain
33. Have you had a pre-term delivery?
 
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Please Explain
34. What was the date of beginning of your last period?
 
   
35. How many pregnancies have you had?
 
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36. How many miscarriages have you had?
 
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Please Explain
37. How many pregnancy terminations have you had?
 
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38. Have you ever had a C-Section?
 
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If "Yes", what was the reason? And how many c-s?
39. Have you had hyperemesis, pre-eclampsia, gestational diabetes, pre-term labor?
 
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40. Have you ever had a "D and C"?
 
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41. Have you ever had pelvic surgery?
 
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42. How many live births have you had?
 
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Weight and Weeks Gestation for each pregnancy
43. What method of birth control do you use?
 
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Please explain "Other"
44. Are you willing to stop or change methods of birth control temporarily?
 
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Please Explain
45. Who is your Ob/gyn? Include phone/fax
 
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46. When was your last Pap?
 
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47. Do you drink?
 
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48. If so, how many drinks do you consume per week? Such as glass of wine, a beer, a liquor drink?
 
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49. Do you smoke or use tobacco products?
 
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If yes, what type and for how long?
50. Does anyone else in the house smoke or use tobacco products?
 
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51. Have you ever used illegal drugs including marijuana or IV drugs and cocaine?
 
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If "Yes", please describe.
52. When is the last time you have used recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)?
 
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Which drugs, and when?
53. Does anyone living in the house use illegal or recreational drugs?
 
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54. How many sexual partners have you been with during the past 12 months?
 
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55. How many sexual partners have you been with in your lifetime?
 
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56. Do you have any tattoos?
 
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If "Yes", when and where on your body.
57. Do you have any body piercings?
 
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If "Yes", when and where on your body.
58. When did you receive your last tattoo or body piercing?
 
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59. If you are not single, is your husband/partner supportive of you being a gestational surrogate?
 
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60. If you are divorced, who has custody of your child(ren)?
 
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Please Explain
61. Have you had a medical diagnosis of ZIKA virus in the last 6 months?
 
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62. Have you resided in or traveled to an area with active locally acquired ZIKA virus, such as Mexico, Caribbean, Central America, South America, Puerto Rico or Pacific Islands?
 
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63. Have you had sexual intercourse in the previous six months with a male who has any of the above risk factors? (Travel or contact)
 
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64. Do your or your partner plan on traveling in the next year to any of the above locations?
 
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65. If you answered "yes" to any of the above questions please explain below otherwise, type in N/A.
 
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Please Explain
66. Have you ever had a blood transfusion?
 
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If "Yes", please explain when and what state/country were you treated.
67. Have you ever had gonorrhea?
 
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68. Have you ever had Human Papilloma Virus (HPV)?
 
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69. Have you had chlamydia within the past 12 months?
 
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70. Do you have herpes? If so, when was last outbreak?
 
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71. Have you ever had Trichomoniasis?
 
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72. Have you ever had Syphilis?
 
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73. Have you ever been exposed to radiation or toxic chemicals, besides routine dental procedures or broken bones?
 
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74. Have you ever been diagnosed with Sever Dysmenorrhea (painful cramps)?
 
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75. Have you ever been diagnosed with Ovarian Cysts?
 
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76. Have you ever been diagnosed with Chronic Pelvic Pain?
 
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77. Have you ever been diagnosed with Polycystic Ovarian Disease?
 
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78. Have you ever been diagnosed with Thyroid Disease?
 
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79. Do you have allergies?
 
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80. Do you take daily medications? If so please name them.
 
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81. Do you take daily vitamins?
 
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82. Do you take any herbal supplements?
 
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83. Have you ever had any major medical problems?
 
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If "Yes", please explain.
84. Are you a vegetarian or vegan?
 
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85. How would you describe your overall health, both mentally and physically?
 
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86. Have you ever taken medications for depression, anxiety, OCD, etc. If so, please explain.
 
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87. How many times have you been a gestational carrier?
 
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88. What is your occupation?
 
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89. Please complete the table regarding your education.
 
Type of Education GPA Degree Area of Study
High School:      
Community College:      
Bachelors Degree:      
Graduate School:      
Professional School:      
90. Do you have children?
 
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91. How many children do you have?
 
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92. What are the ages and sex of your children?
 
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93. Please add any other comments about your health or your immediate family's health history.
 
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94. Please add any comments about you children
 
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95. Why do you want to become gestational surrogate?
 
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96. How did you hear about 3 Sisters Surrogacy
 
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97. Would you allow the intended parents to make all medical decisions concerning their unborn child during the surrogate pregnancy? (This *may* include blood testing, invasive procedures such as amniocentesis, medically necessary reduction or termination, medically necessary c-section, etc. It would not include decisions regarding the surrogates life, should it be in danger.) "
 
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98. What is your email address for communication with you regarding your pre-screen application?
   
98. Please verify your email address
   
99. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
100. Verify your password