Surrogate Application 1 Welcome2 Surrogate Mother Application & Profile3 Insurance4 Diet & Health5 Diet & Health Continued 6 Termination and Amnio7 Intended Parents8 Profile sharing9 Home Life10 Complications Dear Surrogate Applicant, Thank you for applying with Positive Surrogacy. We understand there are many agencies to choose from and find it an absolute honor that you want to work with our team. We strive to be different from the larger agencies out there, by giving you the one on one attention you deserve. You will be treated with respect and dignity. We will also provide you a more individualized support system by finding out your needs first. The Surrogacy journey you embark on is a life changing experience that you will remember the rest of your life. It will impact you, and your family in many different ways. That is why we stand by our word to provide you the support and guidance for your future journey. We understand there can be many ups and downs with the typical Surrogacy journey, but with our own personal surrogacy experiences, we feel we can guide you through anything! Please take your time to review this packet, and contact us if you have any questions. Remember we are just a call or email away. We hope you are as excited as we are to embark on your first Surrogacy journey! First NameLast Name InitialEmailAgeHeightWeightBMIDo you know your blood type?Are you religious or spiritual?Are you bi-lingual?Is your spouse bi-lingual? (If applicable)What is your relationship status?SingleMarriedBoyfriendEngagedSeparatedDivorcedPartnerDescribe your relationship if applicable):How many biological children do you have?Step Children?First names of people that live with you: Please describe your overall health and diet:Are you willing to eat organic foods if future intended parents requested it? Assuming they would cover the extra costs?Do you suffer from any of the below medical conditions? If yes, please check box and describe below:MigrainesTumorsAsthmaHigh or low thyroidLiver diseaseDiabetesGest DiabetesKidney problemsMental illnessEpilepsyConvulsionsDepressionHeart DiseaseADDADHDArthritisTumorsSkin DisordersUlcersTrouble conceivingInfertilityCancerN/APlease describe conditions from aboveDo you have any medical problems we should be aware of?What is your current method of birth control?How long have you used this birth control?Do you have an IUD? Please circle:Select OneYesNoIf you have an IUD, do you agree to schedule an appointment as soon as possible to have it removed?Select OneYesNoN/AOnce the IUD is removed your physician can give you a prescription to start birth control to prepare your body for a future IVF cycle. Have you received the series of vaccinations for Hepatitis B?Select OneYesNoAre you up to date on all your vaccinations?Select OneYesNoAre you currently under the care of a mental health specialist?Select OneYesNoPlease describe reason:Are you currently on any medications, including prescribed and non-prescribed?Select OneYesNoIf yes, what are the names of the medications?Have you ever had an abnormal pap smear?Select OneYesNoIf yes, please describe course of action physician recommended?Please list (month) and (year) of most recent pap smear:Please list the name of your OB physician who took care of your prenatal care during your most recent pregnancy:Do you allow PS to request your OB records and send the records to an IVF Physician to ensure you are a suitable candidate for Surrogacy?Select OneYesNoAs a Surrogate Mother, you will be required to take IVF medications. Some meds require using injectable needles. I agree Name of person providing support:Do you have any questions about IVF medications?Select OneYesNoIf so, please indicate questions below:Do you agree to follow the IVF protocol as instructed by the IVF physician and nurses for a future embryo transfer?Select OneYesNoDo you have any questions about the IVF Cycle or Protocol?Select OneYesNoIf so, please indicate:Are you and your Spouse/Partner willing to complete all requirements requested by a physician, this also means STD testing & Blood work?Select OneYesNoAre you and your Spouse/ Partner willing to abstain from sexual intercourse or stimulation as most IVF physicians will require during IVF?Select OneYesNoMost IVF physicians want to transfer at least two embryos during the IVF cycle, this is to help the couple’s chances of achieving a pregnancy. Because of this, a twin pregnancy could happen!*Are you comfortable with carrying twins?Select OneYesNo(Please note if you become pregnant with twins, it does not mean automatic bed rest & C-section. Every pregnancy is different!)*Are you comfortable with carrying triplets?Select OneYesNoIf you are not comfortable with carrying twins, please give us a call, so we can go over other options with you. Sometimes an IVF physician will recommend a Surrogate undergo selective reduction if a triplet pregnancy occurs. This is because your body is not designed to carry triplets and could cause a health risk to the Surrogate. Please let us know if you are not comfortable with selective reduction. Please also know selective reduction is very rare. Please also know a triplet pregnancy is also rare, but could happen. It is also against policy for an IP to choose selective reduction based on gender. We respect all Surrogates opinions on selective reduction. If you would like to talk to us about this sensitive issue, please call.*Are you willing to allow your IP’s the decision for you to have selective reduction performed if twins occurred? If medically recommended by a physician?Select OneYesNo*Are you willing to allow your IP’s the decision to have selective reduction performed if triplets occurred? If medically recommended by a physician?Select OneYesNo*Are you willing to allow your IP’s the decision to have selective reduction, if in the RARE event of embryos splitting into identical twins, resulting in a triplet pregnancy, in this rare case, it would be medically recommended to reduce the twin sac?Select OneYesNo*Are you willing to allow your intended parents the decision to have selection reduction with no medical reason?Select OneYesNoNotes IVF physicians will recommend to intended parents to have genetic testing on their embryos prior to placing the embryos in the uterus. This is called PGD or PGS. This is to ensure the embryos are healthy and are free of abnormalities, since not all Medical science is 100%, unforeseen things can happen in a pregnancy. In this case, PS finds it necessary to ask the below questions to find the right match for you. *Are you willing to allow your intended parents to make the heartbreaking choice to terminate the Surrogacy pregnancy before 13 weeks of gestation? (For any found medical reasons?)Select OneYesNo*Are you willing to allow your intended parents to make the heartbreaking choice to terminate the surrogacy pregnancy (for any found medical reasons) between 13 and 20 weeks gestation?Select OneYesNo*Are you willing to terminate a surrogacy pregnancy if your own life is at risk as this would turn automatically into an emergency situation?Select OneYesNo*Are you willing to terminate a surrogacy pregnancy if the baby is found to be medically unable to survive after birth due to an abnormality or defect:Select OneYesNoPlease note in the RARE occurrence that selective reduction or termination of the pregnancy resulted, you will be offered support and psychologically counseling immediately. We truly believe that Surrogacy is a huge sacrifice and never want a Surrogate Mother to feel alone. Please call if you ever want to discuss the above questions.*Are you willing to have an amnio if your physician recommended it?Select OneYesNo*Are you willing to have an amnio at your intended parent’s request?Select OneYesNoNotes Positive Surrogacy wants to ensure you are matched with a couple or individual that you are comfortable with sharing a journey with. Please know you have the FINAL say with whom you move forward with as an official match. Please circle below the type of couple of individual you are comfortable with PS sharing your profile with.American intended parents?Select OneYesNoUnsureIf Unsure, please describe why?International intended parents?Select OneYesNoUnsure(Please note with today’s technology, you can still have a great friendship. Skype, email, phone, and many apps can put you in touch with your IP with a touch of a button with any smart phone.)If Unsure, please describe why?International intended parents using a translator?Select OneYesNoUnsure(Please note that sometimes IP’s will hire a translator to understand American law. English sometimes can be hard for them, and they want to be sure before they understand all that is involved with surrogacy, such as the emotional, financial, medical, and legal.)If Unsure, please describe why?Intended parents that have children?Select OneYesNoUnsureIf Unsure, please describe why?Bi-racial couple ?Select OneYesNoUnsureIf Unsure, please describe why?Gay Intended Parents?Select OneYesNoUnsureIf Unsure, please describe why?Single Gay Intended Parent?Select OneYesNoUnsureIf Unsure, please describe why?Single Intended Parent? Male or Female?Select OneYesNoUnsureIf Unsure, please describe why?Intended parents that are Hep B?Select OneYesNoUnsureMost Chinese intended parents are Hep B carriers and not positive. So to be extra safe your IVF physician will test you to see if you are immune to Hep B, prior to placing an embryo into your uterus. If you are under 30 most likely you are immune since you have had the Hep B series of vaccinations. If you are not immune, you can start the series anytime. Are you financially stable?Select OneYesNoDo you work Full Time or Part Time?Full TimePart TimeN/AAre you a stay at home Mother?Select OneYesNoN/AIf you do work, what is your job title?If you do work, will your employer accommodate your pregnancy?If you do work, will your employer be flexible if you need to take off work to attend the necessary appointments for your future Surrogacy?Select OneYesNoN/ADo you qualify for state disability?Select OneYesNoN/AWhat is your current work schedule?What does your partner do for a living?If your spouse is in the military, are there any deployments coming up?Select OneYesNoN/ABesides Positive Surrogacy providing you support during your journey, do you have someone who will provide you additional support, such as spouse, relative or a friend? If yes, please indicate who will be support?Do you have a valid driver’s license?Select OneYesNoDo you have a reliable vehicle to attend the necessary appointments?Select OneYesNoDo you take illegal drugs?Select OneYesNoDo you smoke any tobacco or marijuana?Select OneYesNoDoes anyone in your household smoke?Select OneYesNoDo you drink Alcohol?NoWeeklyMonthlySociallyIf so, how often?Select OneYesNo Please describe why you want to be a Surrogate Mother:Please describe why future intended parents should consider you as their Surrogate?Please describe anything you feel is important for intended parents to know about you:How Many Children Have You Had?123456Child 1 DOB & Gest weeks at birth? Babies birth weight? Gender? Multiple pregnancy? Vaginal or C-Section? Child 2 DOB & Gest weeks at birth? Babies birth weight? Gender? Multiple pregnancy? Vaginal or C-Section? Child 3 DOB & Gest weeks at birth? Babies birth weight? Gender? Multiple pregnancy? Vaginal or C-Section? Child 4 DOB & Gest weeks at birth? Babies birth weight? Gender? Multiple pregnancy? Vaginal or C-Section? Child 5 DOB & Gest weeks at birth? Babies birth weight? Gender? Multiple pregnancy? Vaginal or C-Section? Child 6 DOB & Gest weeks at birth? Babies birth weight? Gender? Multiple pregnancy? Vaginal or C-Section? Have you ever been placed on strict bed rest by a midwife or OB?Select OneYesNoIf Yes, Please describe why:If you were placed on strict bed rest, did you end up delivering full term?Select OneYesNoPlease list all the medications used during pregnancy and delivery:Have you ever had a still born delivery?Select OneYesNoIf so, did you receive support after delivery?Select OneYesNoHave you ever had a miscarriage or abortion?Select OneYesNoList N/A, or how many weeks gestation if circled yes above?Have you ever been diagnosed with Post-partum depression?Select OneYesNoIf so, did you receive emotional support needed to recover?Select OneYesNoIf so, did your physician find it necessary to prescribe medications?Select OneYesNoHave you ever been prescribed depression medications?Select OneYesNoIf so, are you still on the medications?Select OneYesNoHave you ever had any of the below pregnancy complications? Please circle below if applicable. Gestational diabetes Placenta Previa High blood pressure Uterine fibroids Pre-eclampsia Pre-term labor or delivery Placenta Abruption Shorting of the cervix Uterine cysts Ovarian cysts Abnormal Cells on your cervix Cerclage? If you checked any of the above, please explain diagnosis and what happened:Please describe your pregnancies, were they healthy? Were they happy? Full legal nameMaiden NameEthnicity* I understand and agree-Like a check box Cell PhoneWork PhonePhysical AddressPast addressEmailSkype IDWere you born in California? Yes / No If no, what state were you born?Social Security #Driver’s Lic # & StateHave you ever lived outside of the U.S.? Yes / No If so, where? And how long?What is your date of birth:Do you agree that once legal contracts are finalized with future intended parents that you will not travel outside of the U.S.?Select OneYesNoDo you also agree that once you are 23 weeks gestation that you will not travel outside the state of California?Select OneYesNoIVF clinic requirement: Do you agree to not get any new tattoos once you sign this agreement?Select OneYesNoNotesWe believe in finding the right match for you no matter how long it takes. We strongly believe in the philosophy of “we are not about the fast match, but the RIGHT match” Sometimes you can find the right match quickly, sometimes it takes a few weeks. However please do not be discouraged. Behind closed doors, we are continually presenting your profile to couples or individuals whom you are willing to work with. We also want you to be comfortable with your intended parents and future match. This is a couple or individual that you will be involved with for the next year of your life and possibly longer! The end result is that you are helping a couple build their family, How absolutely wonderful is that? Remember if you have any questions, do not hesitate to call! Kindly, Bernadette M.Hendricks Positive Surrogacy Co-founder / Surrogacy Program Director 619-354-7575 Ext 700 Hendricks@positivesurrogacy.comCAPTCHA We Would Love To Speak With You Please give us a call at (619) 354-7575 or contact us below Contact Us
