Potential Surrogate Mother Interest Form

First name

Last name

Street address

City

State(Please select)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip/postal code

Primary phone number

Email

Birthdate

Height (feet)(Please select)4′5′6′

Height (Inches)(Please select)0″1″2″3″4″5″6″7″8″9″10″11″

Weight (lbs)

Number of pregnancies resulting in live birth(s)(Please select)0123456+

Number of cesarean sections(Please select)01234+

Number of miscarriages(Please select)012345+

Do you have Native American heritage?(Please select)NoYes

Have you ever taken medications for depression or anxiety?(Please select)Yes – currentlyYes – within the last six monthsYes – more than six months agoNo

Do you smoke?(Please select)Yes – I smoke currentlyNo – I quit within the last six monthsNo – I quit six months ago or longerNo – I have never smoked

Have you undergone a sterilization procedure called Essure (metal coils) or Adiana (silicone plugs)?(Please select)YesNoI’m not sure

If the intended parents found out that something was medically wrong with the baby and wanted you to terminate the pregnancy, would you be willing to do so?(Please select)YesMaybeNo
How did you hear about us?(Please select)CraigslistFacebookFertility clinicFriend/familyIn-person eventGoogle/web searchOnline adPrint adMovie TheaterRadioTwitterOther

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