Surrogate Application

If this is a cell phone number do you want to receive notifications via text messages *

Yes No

Address *

Line 1

Line 2

City

State

Zip Code

Country

What is your preferred form of communication *

Email Phone Text Other

If other, please explain *

Your Date of Birth *

Do you have Medical Insurance *

Yes No

If yes, which insurance provider *

Spouse/Partners Name *

First

Last

Are you an experienced Surrogate *

Yes No

Total Number of Times You Have Been Pregnant *

Number of Live Births *

Have You Had Any Pregnancy Complications *

Yes No

If Yes please explain *

Have you ever undergone any fertility treatments (medications, insemination, IVF, acupuncture, etc.) to become pregnant *

Yes No

If Yes please explain *

Pregnancy #1 - Date of Birth & Birth Hospital *

Pregnancy #1 - Which Medical Office Provided Prenatal/OB care *

Pregnancy #2 - Date of Birth & Birth Hospital *

Pregnancy #2 - Which Medical Office Provided Prenatal/OB Care *

Pregnancies #3 and More - Please provide dates of births, birth hospitals and which offices provided prenatal/ob care for each pregnancy *

How Would You Rate Your Physical Health *

Excellent Good Average Poor

Have you ever been diagnosed or treated for any emotional disorder *

Yes No

If Yes please explain *

Are you taking any medications *

Yes No

If Yes please explain *

Do you smoke *

Yes No

Are you around anyone who smokes *

Yes No

Do You Use Drugs *

Yes No

Do you have any criminal arrests *

Yes No

If Yes please explain *

Are you receiving any public assistance *

Yes No

If Yes please explain *

Are you available to travel a few times if needed *

Yes, anywhere in the United States Yes, but only within my state of residence No

If you were referred by a friend/family member please tell us their name so they qualify for the referral *

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 *

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. *

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. *

Agree

Surrogate Quick Application

Surrogate - Gestational Carrier Application

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