Surrogate Application Form

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PRELIMINARY QUESTIONS

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

¿Fecha de nacimiento?

Location(Required)

AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands

City

¿En qué ciudad estás ubicada?

Email(Required)

Cellphone Number(Required)

Instagram(Required)

¿Instagram?

How did you hear about us?(Required)

How tall are you and what do you weigh?

¿Cuanto mides y pesas?

How many pregnancies have you had? Childbirth or Caesarean section?

¿Cuantos embarazos has tenido? ¿Parto o Cesarea?

Have you been a surrogate before?(Required)

Yes

No

¿Ya fuiste surrogate antes?

Have you had at least one full-term, healthy pregnancy and delivery?(Required)

Yes

No

Do you have a driver's license?(Required)

Yes

No

Contact Information

Preferred Phone(Required)

May we leave a message identifying ourselves at the number listed above?(Required)

Yes

No

Do you have a Partner or Significant Other?(Required)

PartneredIn a Committed Relationship with a Spouse or Partner SingleNo Committed Partner, Spouse, or Significant Other

Emergency Contact

Please provide the name, relationship and phone number of an emergency contact with whom CFC may reach out should the need arise.

Name

First Last

Phone

Relationship

Home Demographics

How many people currently live in your home?(Required)

Adults(Required)

Children(Required)

Children

How many biological children do you have?(Required)

For each of your biological children, please list the following: first name, date of birth, and father's name(Required)

First name

Date of birth

Father's name

Used IVF (Yes/No)

 

Add Remove

If you used IVF, please indicate that here

Do all of your biological children live with you?(Required)

Yes

No

Do you have any adopted, step, or foster children living with you?(Required)

Yes

No

Religious Views

Current Religion - Including Denomination, if applicable(Required)

Do you have any religious or spiritual beliefs that would limit or prevent your seeking medical attention for yourself or the fetus in any way?(Required)

Yes

No

Firearms/Guns

There are many people in the US who lawfully own licensed guns/firearms. Our goal in asking this question is transparency on responsibility and safety. Please answer truthfully.

Do you keep or store, or have any plans to keep or store, any firearms/guns in your home?(Required)

Yes

No

Personal Health History

Are you currently being treated for any medical conditions?(Required)

Yes

No

Have you ever had a disease or serious illness, including but not limited to: heart disease, cancer, diabetes, kidney disease?(Required)

Yes

No

Please list all medical conditions for which you have you been treated (to include health or mental) in the last 7 years, If none, please indicate.(Required)

Have you ever had a major infectious illness such as hepatitis, meningitis, etc?(Required)

Yes

No

Origen Agency discusses preferences in regard to tobacco, marijuana and CBD use with all Intended Parents before matching. Do you utilize tobacco, marijuana or CBD products?(Required)

Yes

No

Have you ever smoked cigarettes?(Required)

Yes

No

Origen Agency discusses preferences in regard to tobacco, marijuana and CBD use with all Intended Parents before matching. Does your spouse/significant other or any other adult in your home utilize tobacco, marijuana or CBD products?(Required)

Yes

No

In the past 7 years, have you used any form of illegal drug, or taken any prescription drug not prescribed to you by a doctor?(Required)

Yes

No

Are you currently taking any prescription drugs?(Required)

Yes

No

Are you currently taking any over-the-counter medications or treatments (including vitamins, herbal medications, birth control, etc.)?(Required)

Yes

No

Do you have any allergies?(Required)

Yes

No

Have you received the COVID vaccine?(Required)

Yes

No

How many drinks per week do you typically drink?(Required)

Yes

No

Have you ever been treated for drug or alcohol abuse?(Required)

Yes

No

Have you ever experienced postpartum depression or anxiety?(Required)

Yes

No

Have you been treated for any mental health conditions by a mental health professional (to include depression, anxiety, or other mental health conditions)?(Required)

Yes

No

Are you currently receiving any type of counseling or mental health treatment (including marriage counseling)?(Required)

Yes

No

Have you ever experienced emotional, physical, or verbal abuse?(Required)

Yes

No

Reproductive Health History

Total Number of Pregnancies(Required)

Total Number of Deliveries(Required)

Please note that a twin delivery counts as ONE delivery. In other words, the number of deliveries should not be larger than the number of total pregnancies

Any multiple births (twins or triplets)(Required)

Yes, TwinsYes, TripletsNo

Please list ALL of your deliveries in the order in which they occurred

Date of Delivery

Type of Delivery (Singleton/Twins/Triplets)

Baby's weight at birth

Was this a surrogacy delivery? (Yes/No)

Duration (weeks) of pregnancy

Length (hours) of labor

 

Add Remove

Use the plus button on the right to add another delivery

Delivery details

Total Number of C-Sections(Required)

Total Number of Miscarriages(Required)

Total Number of Abortions(Required)

Total Number of Ectopic (Tubal) Pregnancies(Required)

Have you ever had a still birth?(Required)

Yes

No

Did you attend all of your scheduled OB appointments for all of your pregnancies? (This will be verified by your OB)(Required)

Yes

No

When was your most recent pap test?(Required)

MM slash DD slash YYYY

Was your most recent Pap test result normal?(Required)

Yes

No

In the past, have you ever had an abnormal pap test result?(Required)

Yes

No

Have you ever been diagnosed with Gestational Diabetes (GD)?(Required)

Yes

No

Have you ever been diagnosed with an incompetent cervix or uterus?(Required)

Yes

No

Have you ever been diagnosed with endometriosis?(Required)

Yes

No

Were any of your pregnancies considered high risk by your physician, or has your physician ever told you that a future pregnancy might be high risk or result in the need for bed rest?(Required)

Yes

No

Were you on bed rest for any portion of your pregnancies?(Required)

Yes

No

Were all of your children born healthy?(Required)

Yes

No

Did you experience postpartum depression after any of these pregnancies?(Required)

Yes

No

Have you experienced any complications with any of your pregnancies or deliveries?(Required)

Yes

No

Would you describe any of your pregnancies or deliveries as difficult?(Required)

Yes

No

Did you experience morning sickness?(Required)

Yes - extremeYes - averageYes - mildNo

Did you experience fluid retention?(Required)

Yes - extremeYes - averageYes - mildNo

Did you need any special medical assistance to conceive your children?(Required)

Yes

No

What type of birth control are you currently using?(Required)

Please Note: IVF Clinics will require a potential surrogate to remove an IUD and then have at least 2-3 regular cycles before attending medical screening. You will be asked to remove the IUD during the application process.

Would you be willing to use a condom during the pregnancy?(Required)

Yes

No

Are you currently nursing a baby?(Required)

Yes

No

How many sexual partners have you had in the last five years?(Required)

How many sexual partners have you had in the last 12 months?(Required)

When answering the next question, please consult this list of sexually transmitted diseases:

• Chlamydia
• HPV (the virus that causes genital warts)
• Nonspecific Urethritis (NU)
• Genital Herpes (HSV)
• Pelvic Inflammatory Disease (PID)
• Gonorrhea
• Syphilis
• HIV
• Other not listed above

Please indicate if you or any of your partners have had any of the above-listed (or other) sexually transmitted diseases within the past twelve months(Required)

In the last twelve months have you received blood transfusions, blood injections, tattoos, piercings, organ or tissue transplants?(Required)

Yes

No

Are you willing to refrain from having any tattoos during the cycling and pregnancy process?(Required)

Yes

No

Have you ever tested positive for HIV?(Required)

Yes

No

Been sexually assaulted?(Required)

Yes

No

Had acupuncture, ear and/or body piercing, or tattooing in which sterile procedures may not have been used in the last 12 months?(Required)

Yes

No

What to tell IPs

What can you tell us about yourself and your family for us to share with potential Intended Parent(s)?

Ex: hobbies, favorite things to do together, do you like sports, exercise, cooking, have any pets, etc.

Your Thoughts About Surrogacy

Please be completely honest - we do not judge, we just want to make sure that we are able to make the right match!

Do you want to have any more children of your own?(Required)

Yes

No

A surrogacy pregnancy, as with any pregnancy, can cause a risk to your future fertility. Knowing these risks, are you comfortable moving forward as a gestational surrogate?(Required)

Yes

No

A surrogacy journey requires up to 15 weeks of hormonal medications, some of which are self injectables. Are you comfortable giving yourself shots?(Required)

Yes

No

Please explain your personal reasons for wanting to be a gestational surrogate(Required)

What would you tell Intended Parent(s) to reassure them that you would never want to keep the baby?(Required)

During the surrogacy process, from whom do you expect to receive emotional support?(Required)

How does your spouse/significant other feel about your being a surrogate?(Required)

Please share your thoughts about the type of Intended Parent(s) you and your spouse/significant other (if applicable) wish to help, and your views on working with LGBTQ Intended Parent(s)(Required)

As a gestational surrogate, would you be willing to follow all the specific pregnancy regime recommended by your doctor?(Required)

Yes

No

Have you identified an OB/GYN to handle your surrogacy journey?(Required)

Yes

No I plan to use a Midwife

If you already know which hospital will likely be your delivery hospital, please provide us with the name, address, and contact information.(Required)

Did you see a Maternal Fetal Medicine (high-risk) doctor for any of your pregnancies, for any reason?(Required)

Yes

No

Would you be willing to do a sibling journey with your Intended Parents in the future, assuming that your initial journey goes well, and you are medically cleared for another journey?(Required)

Yes

No

Undecided

Prior Surrogacy Experience

Have you ever previously been a surrogate?(Required)

Yes

No

Timing

Are there any time constraints on how soon you would be ready to begin the surrogacy screening process?(Required)

Yes

No

Are there any time constraints on how soon you would be ready to become pregnant as a surrogate?(Required)

Yes

No

Education

Please share the highest level of education you have obtained(Required)

Employment

Are you currently employed?(Required)

Yes - Full-timeYes - Part-timeNo - Not employed

What is your total yearly household income, after taxes? $(Required)

This can be an average or estimate, and can include separate maintenance income from a spouse, significant other (who lives in the home and contributes to living expenses) or from child support or alimony, etc. Please DO NOT INCLUDE any income received from government assistance

Does your household have any other sources of income?(Required)

Yes

No

Health Insurance

Do you have health insurance?(Required)

Yes

No

Criminal Background and Credit Checks

Do you have any objections to our running a criminal check on you?(Required)

Yes

No

Will anything show up when we do a criminal background check on you or your spouse/significant other?(Required)

Yes

No

That's it! You are done!
Just click the submit button to send your application for review.
If you have questions about the form, please email team@ivforigenagency.com.
Thank you! We hope you take your surrogacy journey with us.