Initial Surrogate Application | Simple Surrogacy, LLC

Legal First Name:

Legal Last Name:

Maiden Name if Married

Email address:

Preferred phone number:

Country

Street Address:

Street Address (line 2 if needed):

City:

State:

Zip Code:

Date of Birth:

Sun Mon Tue Wed Thu Fri Sat

Height:

'

"

Weight:

lbs

Marital Status - We MUST know your legal status, it can affect the Legal contract and your ability to be a surrogate.

Please review the following Surrogate qualifications and indicate your understanding:

Are you a citizen or permanent resident of the United States?

What country are you a Citizen of?

Are you between the ages of 21-44?

Have you given birth to a child of your own, who is in your care?

Have you had at least 1 delivery, but no more than 5 and no more than 3 prior c-section deliveries?

Have you had uncomplicated pregnancies and deliveries

Do you have a valid driver's license or resident ID?

Are you in a stable living situation (7 year address verification is completed on all Surrogates) with no talk of divorce in your relationship?

Do you have the support of your spouse or partner (when applicable) or family?

If Married, your spouse must be able to sign documents along side you. If they will not sign, you must be fully divorced to be a surrogate without their signature.

Do you have any felony convictions?

Have you read and understood the Surrogacy process, as listed on our website?

Are you willing to take medications via injection (when instructed by Doctor)?

Do you smoke, or vape, or take illegal drugs or legal drugs, or are you exposed to second hand smoke?

Will you refrain from consuming alcohol, smoking and vaping, and taking legal or illegal drugs during the selection, screening and pregnancy?

Do you have any sexually transmitted diseases that would subject you or the child you are carrying to physical harm?

Do you have any psychiatric illnesses or take medications for depression or anxiety?

Do you have reliable transportation to travel to the Doctor's appointments and screening or matching appointments?

Have you had any tattoos or piercings within the past 12 months? If yes, are you able to get a picture of the license from the facility?

Are you able to provide contact information for past OBs or family doctors so we are able to obtain medical records

Will you sign necessary forms (HIPPA or medical release) to allow us access to Medical records from previous pregnancies, and surrogacy journeys?

Have you traveled to any countries in the past 6 months where there is an active Zika Virus transmission, including Brazil, The Caribbean, Mexico or Cape Verde, Africa? Or have plans to travel in the next year to those locations?

How did you Hear about Simple Surrogacy?

Please tell us who referred you so we can thank them.

What city and state was the billboard in?

Are you applying for a specific Intended Parent? (That you are a friend of or you saw on social media.)

Please state the name or Number of the IP(s)

Are you ready to apply now to be a Surrogate?

Yes

No

Just Want Information