CCRM - Gestational Carrier
Coronavirus Update: We are continuing to accept surrogate applications at this time, the first portion of the screening process can take place in the comfort and safety of your home. We thank you and look forward to sharing this most amazing experience with you!-Your CCRM Surrogacy Team
1. First Name
 
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2. Last Name
 
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3. Address
 
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4. City
 
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5. State
 
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6. Zip
 
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7. Telephone 1 (e.g. 303-123-1234):
 
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8. Date of Birth:
 
   
9. Have you ever been pregnant?
 
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10. How many times have you been pregnant?
 
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11. Were all of your deliveries full-term (over 37 weeks)?
 
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If "No", please provide additional information.
12. How many C-Sections have you had?
 
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13. Did you have any complications with pregnancy or delivery?
 
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Please explain any complications.
14. How many miscarriages, abortions or ectopic pregnancies have you had?
 
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15. Have you ever been a gestational carrier or a surrogate?
 
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16. Are you currently parenting all of your children?
 
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If "No", why?
17. Height
 
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18. Weight
 
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19. Have you ever had any of the following: AIDS-HIV, Pelvic Inflammatory Disease, Liver Disease or Syphilis?
 
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If applicable, indicate disease, onset date(s) for the items and treatment.
20. Have you ever had any of the following: Chlamydia, Gonorrhea, Herpes, Blood Transfusion, or other major health issues?
 
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If applicable, indicate disease, onset date(s) for the items and treatment.
21. Over the past 6 months, how many sexual partners have you had?
 
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22. What is your current method of birth control?
 
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If other, please explain
23. Are you currently taking any medications/treatments (including non-prescription)?
 
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If "Yes", list any medications & reasons for taking them
24. Have you taken any anti-depressant or psychotropic medications in the last 6 months?
 
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25. Do you currently smoke cigarettes, e-cigarettes or vape (regardless of whether you are regular or casual smoker)?
 
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26. When was the last time you used marijuana?
 
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27. When is the last time you have used recreational or illicit drugs (cocaine, LSD, heroin, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)?
 
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28. Have you had any tattoos or body piercings within the last 12 months?
 
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If have tattoo or piercing, please specify the date of your most recent tattoo or body piercing
29. How did you learn about us? (check all that apply)
 







Please provide "other":
30. As a gestational carrier, I understand that the primary requirements for application are that I be a female between the age of 19-40, a non-smoker, non-drug user, and that I am neither significantly over or under weight for my height.
 
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31. As a gestational carrier, I understand I will be required to be on medications including injectables for up to 4 months.
 
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32. Do you have reliable transportation?
 
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33. Are you currently on any of the following forms of government assistance?
 
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34. Are you currently involved in any legal matters (bankruptcy, divorce, custody issues, arrests)?
 
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If "Yes", please provide additional information.
35. By selecting "Agree", you are stating that you will add: no-reply@donorapplication.com to your email contact list to prevent our responses from being flagged as spam. You may still need to check your Junk or Spam box for these emails.
 
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36. I enter my full name in the field below as a verification of the information I have provided above. I certify that all information provided is honest and factual.
 
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37. What is your email address for communication with you regarding your pre-screen application?
   
37. Please verify your email address
   
38. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
39. Verify your password