Thank you for your interest in becoming a Gestational Carrier with 3 Sisters Surrogacy. As three professionals in the field of Reproductive Health and Business we bring a combined 45 years of professional experience. As the only agency dedicated to caring for the whole person, we will provide you tool and experience you will need to successfully assist a family with their dreams of parenthood while enhancing your own life! We are so glad you are considering us.
1. Have you had a medical diagnosis of ZIKA virus in the last 6 months?
 
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2. 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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3. 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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4. 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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5. Do your or your partner plan on traveling in the next year to any of the above locations?
 
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6. How did you hear about 3 Sisters Surrogacy
 
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7. First name
 
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8. If you answered "yes" to any of the above questions please explain below otherwise, type in N/A.
 
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Please Explain
9. Last Name
 
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10. What is your city?
 
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11. What is your primary phone number?
 
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12. What is your street address?
 
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13. What is your state?
 
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14. What is your zip code?
 
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15. What race would you most likely be affiliated?
 
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16. What is your marital status?
 
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17. What is your date of birth?
 
   
18. What is your height?
 
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19. Do you have health insurance that does not exclude gestational surrogacy?
 
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20. Please provide us with your email address used for this application.
 
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21. What is your weight in pounds?
 
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22. Please provide us with your email address
 
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23. 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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24. Have you had per-term labor?
 
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Please Explain
25. Have you had a pre-term delivery?
 
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Please Explain
26. How many pregnancies have you had?
 
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27. How many miscarriages have you had?
 
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Please Explain
28. How many pregnancy terminations have you had?
 
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29. Have you ever had a C-Section?
 
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If "Yes", what was the reason?
30. How many live births have you had?
 
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Weight and Weeks Gestation for each pregnancy
31. What method of birth control do you use?
 
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Please explain "Other"
32. Have you had hyperemesis, pre-eclampsia, gestational diabetes, pre-term labor?
 
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33. What is your occupation?
 
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34. Do you drink?
 
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35. Do you smoke or use tobacco products?
 
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If yes, what type and for how long?
36. 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?
37. How many times have you been a gestational carrier?
 
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38. Why do you want to become gestational surrogate?
 
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39. What is your email address for communication with you regarding your pre-screen application?
   
40. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
41. Verify your password.
   

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