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Surrogate - Gestational Carrier Application
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Indicates required field
Name
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First
Last
Email
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Phone Number
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If this is a cell phone number do you want to receive notifications via text messages
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Yes
No
Address
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Line 1
Line 2
City
State
Zip Code
Country
What is your preferred form of communication
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Email
Phone
Text
Other
If other, please explain
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Your Date of Birth
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Do you have Medical Insurance
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Yes
No
If yes, which insurance provider
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Spouse/Partners Name
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First
Last
Are you an experienced Surrogate
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Yes
No
Total Number of Times You Have Been Pregnant
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Number of Live Births
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Have You Had Any Pregnancy Complications
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Yes
No
If Yes please explain
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Have you ever undergone any fertility treatments (medications, insemination, IVF, acupuncture, etc.) to become pregnant
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Yes
No
If Yes please explain
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Pregnancy #1 - Date of Birth & Birth Hospital
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Pregnancy #1 - Which Medical Office Provided Prenatal/OB care
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Pregnancy #2 - Date of Birth & Birth Hospital
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Pregnancy #2 - Which Medical Office Provided Prenatal/OB Care
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Pregnancies #3 and More - Please provide dates of births, birth hospitals and which offices provided prenatal/ob care for each pregnancy
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How Would You Rate Your Physical Health
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Excellent
Good
Average
Poor
Height
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Weight
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Have you ever been diagnosed or treated for any emotional disorder
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Yes
No
If Yes please explain
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Are you taking any medications
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Yes
No
If Yes please explain
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Do you smoke
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Yes
No
Are you around anyone who smokes
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Yes
No
Do You Use Drugs
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Yes
No
Do you have any criminal arrests
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Yes
No
If Yes please explain
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Are you receiving any public assistance
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Yes
No
If Yes please explain
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Are you available to travel a few times if needed
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Yes, anywhere in the United States
Yes, but only within my state of residence
No
How did you hear about A Family Tree Surrogacy, LLC
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Google
Bing
From Family/Friend
Facebook
Twitter
Other Social Media
Fertility Clinic
Craigslist
Other
If you were referred by a friend/family member please tell us their name so they qualify for the referral
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By selecting "Agree", you are stating that you will and you have answered all questions to the best of your ability, without purposeful omission or deception. You understand being a surrogate is a serious responsibility and a process that requires maturity, excellent communication, honesty and a willingness to help others
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Agree
By selecting “Agree”, you understand the following: Some of the questions in this application are very personal. No answers will be shared with anyone outside of A Family Tree Surrogacy, LLC without your permission. Certain questions and answers are not shared with recipients and are only used for our internal purposes.
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Agree
By selecting "Agree", you are stating that you understand the treatment involves a psychological evaluation, medical testing, a legal contract drafted by an attorney, and frequent visits to a fertility center. You may need to administer injections to yourself daily, for a period of weeks. You will also undergo blood draws and vaginal ultrasounds at the fertility clinic. Becoming pregnant as a surrogate is not a simple process.
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Agree
Questions/Comment
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Promo Code
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Submit
Home
Surrogates
Compensation
Steps to Becoming a Surrogate
Application
Surrogate Mother Referral Bonus
Intended Parents
Find A Surrogate
LGBTQ+ Surrogacy
Costs and Financing
Surrogate Mother Profiles
Intended Parent Quick Application
About
Contact
Blog
Fertility Clinics
Egg / Embyro Donation
>
Egg Donor Application
News & Events