Great Beginnings Surrogacy
1. Full Name
 
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2. Address, including City, State and Zip Code
 
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3. Phone Number
 
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4. What is your Date of Birth?
 
   
5. How tall are you?
 
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6. How much do you weigh?
 
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7. What made you decide you wanted to become a surrogate?
 
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8. Although surrogacy is a wonderful process for virtually all women, it does involve significant responsibilities and time. How will you be able to add surrogacy with all your other current responsibilities?
 
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9. Are you able to exactly following physician’s orders without deviation or modification?
 
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10. Are you able to commit 100% to this process for the 12-18 months involved?
 
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11. Are you Hepatitis B Immune?
 
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If No, Please Explain
12. Are you willing to complete the vaccination or booster process for HepB immunity?
 
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13. Date of most recent tattoo?
 
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14. Date of most recent piercing?
 
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15. Date of your most recent delivery?
 
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16. What is your contact preference?
 
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17. Date you stopped most recent breastfeeding?
 
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18. Current Contraception (What You Use to Keep From Getting Pregnant)?
 
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19. How many children do you have?
 
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20. What is the age and gender of each child?
 
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21. About your pregnancies
 
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Total number of pregnancies:  
Number of Vaginal Deliveries:  
Number of C-Section Deliveries:  
22. Number of weeks and days at birth for each child
 
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23. Were there any complications/problems with any deliveries?
 
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If yes, please provide the details (especially the number of weeks each complication / problem occurred).
24. Have you been a surrogate before?
 
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If yes, please provide the details.
25. About your surrogacy attempts
 
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Number of attempts:  
Number of pregnancies:  
Number of deliveries:  
26. Please provide the name of the agency you worked with (or enter n/a if you have never worked with another agency).
 
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27. Do you have any problems/concerns with the surrogacy process?
 
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If yes, please explain.
28. What led you to apply with Great Beginnings?
 
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29. Do you have health insurance?
 
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30. Do you have Covered California?
 
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31. Name of Insurance Company
 
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32. Does your insurance cover surrogacy?
 
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33. Do you smoke?
 
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34. Do you drink?
 
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35. Do you take illegal drugs?
 
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36. Have you ever filed for bankruptcy?
 
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Please provide the dates of the filing(s).
37. Are you on any government assistance?
 
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If yes, please describe the assistance.
38. Have you ever been arrested?
 
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If yes, please explain when and why you were arrested, and what was the final outcome(s).
39. Total number of adults living in your home (including you)
 
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40. How many adults living with you smoke?
 
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41. How many adults living with you have been arrested?
 
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Please provide the details of when, arrested for what reason, and what was the final outcome?
42. Do you have any medical problems?
 
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Please explain.
43. Are you on any medications?
 
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Please describe.
44. Do you have family support for surrogacy?
 
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45. Does your support system live within 5 miles of your residence?
 
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If no, how many miles?
46. Are you comfortable with giving yourself injections to prepare your body for an Embryo Transfer?
 
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47. Are you willing to travel for the Embryo Transfer at no cost to you?
 
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If no, please explain.
48. What is your email address for communication with you regarding your pre-screen application?
   
48. Please verify your email address
   
49. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
50. Verify your password