Northwest Surrogacy Center

City

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Zip Code

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E-mail Address

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Birthdate

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Height (feet)

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Height (Inches)

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Weight (lbs)

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Do you have Native American heritage?

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Number of pregnancies resulting in live birth(s)

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Have you ever taken medications for depression or anxiety?

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Do you smoke?

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Number of cesarean sections

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Number of miscarriages

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IVF clinics are requiring the Covid-19 vaccination for surrogates. Are you vaccinated for Covid-19?

Please indicate whether you been vaccinated for Covid-19

Although extremely unlikely, if a serious medical problem with the baby is discovered, most intended parents would like the option to consider termination of the pregnancy. This could be a range of medical reasons that prevent an acceptable quality of life, including chromosomal anomalies like Down Syndrome. Would you be comfortable with intended parents making the decision to terminate based on their personal beliefs and the advice of their doctors?

Please select your willingness to terminate for medical conditions

How did you hear about us?

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If you were referred by a friend or family member, what is that person's name?