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  The level of care of matching me with the IP really made a huge difference. My experience as a surrogate was a beautiful one. I got along so well with my IP’s. We will be friends for a long time to come.  
  » Alice  
  I am so thrilled to be matched with my IP. I feel like we are two peas in a pod. We go shopping together. We are now taking a cooking class together. I never expected to have this type of relationship with my IP. Thank you for matching us.  
  » Nikka  
  Communication is so important to me. I know that I can be a little crazy about communication. Thank you for giving me your personal cell phone number. It made me feel like you were so accessible. Thanks!!!  
  » Lisa  
  I think you are the best coordinator. Thanks for being so calm about everything. It helped me through the whole experience.  
  » Barbara  
Infertility affects about 1 out of every 6 couples. It is more than just the inability to conceive after 12 months of trying, but also includes those that cannot carry a pregnancy to term. Surrogacy is presented as an option to couples who otherwise would not be able to have children.

In the past it was assumed when a couple did not conceive a child on their own they should turn to adoption to achieve their parenthood dreams. This notion is now quite outdated as there are far more options for infertile couples as well as singles and homosexuals who want children. Now people have the option to pursue advanced infertility treatments and egg, sperm and embryo donation are no longer rare, national and international adoption is commonplace and surrogacy is becoming increasingly popular.

A simple desire to have a child can easily become an overwhelming process of making unexpected choices all of which have many unknowns. This notion is now quite outdated as there are far more options for infertile couples as well as singles and homosexuals who want children.
Personal Profile
Has your partner every been arrested or convicted of a crime? If yes, please explain:Yes  No  N/A  
Skype username (if applicable):
Willing to terminate the pregnancy at the sole discretion of the Intended Parents?:Yes  No  
How did you hear about us? (If online, please be specific)*:
Date of Birth: 
First Name*:
Middle name:
Last name*:
Social security number::
Phone number*:
Re enter password*:
Emergency Contact Person*:
Emergency Contact Phone Number*:
Are you on WIC, or any government assistance?:
Blood Type:
Do you have Medical Insurance?:Yes  No  
Does your Insurance have a Surrogacy exclusion?:Yes  No  
Previous Surrogate?:Yes  No  
Willing to Travel?:Yes  No  
Willing to Reduce?:Yes  No  
Are you open to an amniocentesis?:Yes  No  
Willing to terminate the pregnancy at the parent’s request if developmental abnormalities are detected?:Yes  No  
Wiling to carry Multiple Fetuses?:Yes  No  
Willing to work with International Parents?:Yes  No  
Current Location:
Place of Birth:
Can you legally work in the United States?:
Religious affiliation:
Ethnic Background:
Do you have any pets? If so , what type of pet. :Y  N  
Is anyone in your family a member of a tribe? Are they registered with a tribe? If yes, which tribe. :
Do you own a car? If no, do you have reliable transportation?:Y  N  
Are you willing to travel for medical procedures related to your surrogacy?:
Would you require childcare in order to attend appointments associated with surrogacy?:
Have you ever been a surrogate before?:
Gestational Surrogate/ Traditional Surrogate:Gestational Surrogate  Traditional Surrogate  Open to both   
Have you ever been arrested or convicted of a crime? If yes, please explain:Yes  No  
Have you ever been convicted of a felony?:
Have you ever placed a child up for adoption?:Yes  No  
Have you ever filed for Bankruptcy?:Yes  No  
Have you ever filed for a divorce or legal separation?:Yes  No  
Have you ever been refused by an adoption agency?:Yes  No  
Have you ever been past due on child support?:Yes  No  
Do you currently have any legal cases pending? If yes, please explain:Yes  No  
Education and Occupation
What is your highest level of education achieved?:
What was your course of study?:
Who is your current employer?:
Job Title?:
Years at current employment?:
Number of hours worked per week:
If less than 2 years, please provide your previous occupation:
Years at previous occupation:
If unemployed, how are you financially supported?:
Significant Other
Marital Status:
If you are married, what is your husband’s name.:
Occupation of Partner:
Partner’s Date of Birth: 
Number of years together:
Will your significant other support your decision to be a surrogate?:
Do you currently have medical insurance?:
Who is your health insurance provider?:
Policy Number:
Effective Date::
What is your monthly insurance premium::
What is your yearly deductible::
Type of Coverage (Please select the appropriate amount):Other  80%  100%  
Insurance Contact information:
Surrogacy Exclusions? :
Is your policy issued through your employer?:
Which employer?:
Do you have car insurance?:
Who is your car insurance provider?:
Health History
Have you had microblading and/or semi/permanent makeup done within the last year? If yes, when and what type?*:
Have you been vaccinated for Hepatitis B?:Yes  No   I am not sure  If Yes, When:  
Have you or your partner/spouse ever been diagnosed with the following conditions? If yes, please explain:
Herpes:Y  N  
Hepatitis B:Y  N  
Hepatitis C:Y  N  
Gonorrhea:Y  N  
Syphilis:Y  N  
Do you have any of the following health conditions now, or have you had them in the past? If yes, please explain::
Anemia:Y  N  
Asthma:Y  N  
Cystic Fibrosis:Y  N  
Depression:Y  N  
Diabetes:Y  N  
Eating Disorders:Y  N  
Heart Problems:Y  N  
High Blood Pressure:Y  N  
Migraine Headaches:Y  N  
Muscular Dystrophy:Y  N  
Neck/Back Problems:Y  N  
Ovaries Cysts:Y  N  
PID:Y  N  
Seizures/Fits:Y  N  
TB or TB exposure:Y  N  
Thyroid Problems:Y  N  
Uterine Fibriods:Y  N  
How is your general health?:
Do you have any allergies?:
How often do you exercise?:
Please describe your diet:
Do you have any of the following health conditions now, or have you had them in the past? If yes, please explain::Neck/Back Problems  Ovarian Cysts  PID  Seizures/Fits  TB or TB Exposure  Thyroid Problems  Uterine Fibroids  Anemia  Asthma  Cystic Fibrosis  Depression  Diabetes  Eating Disorders  Heart Problems  High Blood Pressure  Migraine Headaches  Muscular Dystrophy  
Do you currently suffer from any medical conditions? If yes, please list any past medical conditions: :Yes  No  
Do you feel you were ever a victim of sexual, physical, or psychological abuse? If yes, please explain::Yes  No  
Have you ever been treated for any emotional disorders? If yes, please explain::Yes  No  
Have you ever been clinically diagnosed with depression or bipolar disorder?:Yes  No  
Are you taking any prescription or over the counter medications? If so please list any medications that you are currently taking::Yes  No  
Do you drink?If yes, how much and how often?:Y  N  
Does your partner smoke? If yes, please explain::Y  N  
Do you smoke or use tobacco? If yes, how much and for how long?:Y  N  
Have you ever used recreational drugs? If yes, please explain. :Y  N  
Have you ever been in a substance abuse program? If yes, please explain::Yes  No  
Have you ever been refused as a blood donor? If yes, please explain:Y  N  
Do you have any tattoos or piercings? If yes, how recent?:Y  N  
Have you ever had any major surgeries?If yes, please explain:Y  N  
Have you ever had cosmetic surgery? If yes, please explain:Y  N  
Have you ever had a blood transfusion?:Yes  No  
Have you ever been diagnosed with Asherman’s Syndrome?:Yes  No  
Have you ever been under the care of a Psychiatrist or Psychologist?:Yes  No  
Have you ever been hospitalized for Psychiatric care?:Yes  No  
Do you have a history of easily bruising or bleeding?:Yes  No  
Have you ever suffered from Anorexia or Bulimia?:Yes  No  
Have you ever thought about committing suicide?:Yes  No  
Have you ever attempted suicide?:Yes  No  
Have you ever intentionally hurt or caused yourself any physical harm?:Yes  No  
Contact Information