Gestational Carrier Candidate Screening Application

First Name

Last Name

Phone Number

Preferred method of contact

Phone call

Text

Other

City

State

Zip Code

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Today Clear

Height

Weight

lbs

Marital Status

Have you had at least one previous successful pregnancy and birth?

How many live births have you had?

Have you had a miscarriage or terminated a pregnancy?

Yes

If yes, please specify:

Have you experienced or been diagnosed with any of the following pregnancy complications? **Please mark all that apply and note these conditions do not automatically disqualify you.

Abnormal pap smear

Adiana or Essure procedure

Anxiety

Depression

Bi-Polar disorder

Drug addiction and/or rehab

Bed rest for a singleton pregnancy

3 or more C-Sections

5 or more total deliveries

Pre-Eclampsia

PIH (Pregnancy Induced Hypertension)

HSV Positive

Hyperthyroidism

Post-partum depression

Criminal history

Non-US Citizen

Gastric bypass surgery

Gestational diabetes

Consumed tobacco or cannabis products in the last 12 months

Medicaid

Hypertension in pregnancy

Uterine abnormalities (ex., bicornuate uterus)

Placenta previa

Miscarriage at greater than 20 weeks' gestation

Placenta acreta, percreta, or increta

Placental abruption

Incompetent cervix

Prior LEEP or conization

Molar pregnancy

None of the above

Have you ever been a Gestational Carrier before?

If you answered yes, please provide details of your last journey including agency, fertility clinic/doctor you worked with, number of transfers attempted to attain pregnancy, and date of delivery/outcome.

If you checked any of the above, please explain:

Have you ever been told by a reproductive endocrinologist that you did not qualify to continue as a gestational carrier?

Yes

Please explain:

Have you placed any children for adoption?

Yes

If yes, please give the details of your circumstances at the time of each placement:

If you have birthed children who have not been placed for adoption but do not live with you, please explain the reason below:

Are you willing to follow ALL medical recommendations given to you by your care provider during a surrogate pregnancy?

Yes

Do you know of anyone who has been a Gestational Carrier before?

What initial questions do you have for us about the surrogacy process?

Are you willing to participate in a psychological evaluation?

Yes

If you are in a committed relationship, is your spouse willing to participate in a psychological evaluation?

Yes

Unsure

Are you willing to sign Releases for The Surrogacy Center, the Intended Parents you select, and the Clinic to receive medical information from your medical care provider?

Yes

Unsure

Are you willing to travel for any surrogacy-related procedures?

Yes

As part of the Frozen Embryo Transfer (FET) process, you will be required to take daily medications to prepare your uterus for transfer, and subsequently support a developing pregnancy. These daily medications may be administered by mouth, vagina, transdermal patch, SQ injection and IM injection. *Please note that the clinic will provide medication training and detailed instructions before the start of your cycle. You will be required to continue some medications after positive pregnancy, as directed by the clinic. This can mean IM injections of Progesterone in Oil for about 10 weeks. Most surrogates have their husbands or partners do the injections, but some choose to do it themselves.

Are you comfortable taking daily IM (intramuscular injections) medications?

Yes

Are you comfortable receiving daily injections for an extended period of time?

Yes

Are you willing to give up cigarettes, vaping, drugs, medications (other than those approved by your physician), caffeine, and dangerous activities prior to and during a surrogacy/gestational carrier arrangement?

Yes

Unsure

Please explain:

We understand the topic of pregnancy termination is very sensitive. This is especially true in relation to a surrogacy journey. While most embryos do undergo genetic testing prior to transfer, it is impossible to ultimately predict if the fetus will have a serious genetic abnormality, medical condition, or other diagnosis that could potentially affect long-term quality of life. Please select all that apply to you:

Please review the following and select all which apply to your feelings on this subject:

I am comfortable following the lead of intended parents in regard to their decision to terminate a pregnancy in which a serious abnormality, medical condition, or diagnosis that is determined to be incompatible with life outside the womb OR that may adversely affect the quality of life of the child outside of the womb is discovered.

I am comfortable terminating a pregnancy at the advisement of a medical professional if my life is at risk.

I am NOT comfortable following the lead of intended parents in regard to a their decision to terminate a pregnancy in which a serious abnormality, medical condition, or diagnosis that may adversely affect the quality of life of the child outside of the womb is discovered.

I am NOT comfortable with terminating a pregnancy under any circumstance, including those noted above.

How did you hear about us?

Google

Clinic referral

Social Media

Personal referral

Other

If this is a personal referral, please share individual's name:

If other, please specify: