Complete Conceptions - surrogacy
1. FIRST name
 
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2. LAST name
 
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3. What is your street address? (apartment number too if appropriate)
 
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4. City
 
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5. State (IN, MI, OH ...)
 
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6. Zip Code / Postal Code
 
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7. What is your primary phone number for phone calls, messages and text notifications?
 
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8. Are you a US Citizen and eligible to work?
 
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9. Which of the following do you have?
 

















Provide details for any of the above.
10. Please check any of the following that apply to you.
 






Provide details to any of the above.
11. Do you have medical insurance?
 
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12. Please provide the following information regarding your transportation:
 












Provide details to any of the above.
13. When is your birthday?
 
   
14. What is the closest description of your race?
 
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If multi-racial, please provide your closest description.
15. What is your height?
 
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16. What is your weight?
 
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17. What is your body frame?
 
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18. What is your highest level of completed education?
 
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19. What is your current marital status?
 
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20. How many healthy, live babies have you given birth to?
 
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21. Have any pregnancies required fertility treatment?
 
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What was the issue (if known)?
22. Are you currently breastfeeding?
 
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23. Are your periods regular when not on birth control pills?
 
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Please explain
24. How long usually from the beginning of one period to the next?
 
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25. How often do you use tobacco products of any kind (including vapor, e-cigs)?
 
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26. How many people with whom you live smoke?
 
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27. What were the results of your most recent Pap Smear? (provide date)
 
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28. Please describe all medical issues / treatments related to the pelvic area, inclusive of the cervix, uterus, and endometrium.
 
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29. How often do you consume alcoholic beverages?
 
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What type of alcoholic beverages and how much in an average day?
30. How often do you smoke or consume marijuana products?
 
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31. What birth control method(s) are you currently using?
 
















32. When is the last time you have used recreational drugs, such as heroin, cocaine, barbituates, etc.?
 
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Which drugs and how often?
33. In the past 12 months, have you or any of your partners had or have an STD?
 
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34. How many times have you been arrested? (note: DUI is an arrest, speeding tickets and traffic violations are not)
 
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Please provide additional information (arrested for?, when?, ...)
35. Is there anyone who has a restraining order to stay away from you?
 
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Please explain the details of the order.
36. Do you have an officially registered case of abuse of you?
 




37. Do you have unofficial cases of abuse of you?
 




38. Are you willing to make lifestyle changes based on a physician's recommendation?
 
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39. Are you willing to make lifestyle changes based on the recipient(s) preference?
 
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40. What is your email address for communication with you regarding your pre-screen application?
   
40. Please verify your email address
   
41. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
42. Verify your password