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Please call us if you have
any questions 619.579.6510
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Fill in the required fields below.
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First Name: *
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Last Name: *
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Age: *
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What is your height?
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What is your exact weight?
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Ethnic background:
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Religious background:
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Photo:
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Home Phone: *
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Cell Phone: *
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Home Address: *
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E-Mail Address: *
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* Invalid Email Address
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City: *
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State: *
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*
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Zip: *
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*
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Are you a United States Citizen?
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Have you ever been a Surrogate Mother before?
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If so, please briefly describe the details of your experience.
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What type of Surrogate do you want to be?
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How soon would you like to begin the process?
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Are you willing & able to travel to LA for up to 10 Dr. visits in a 2 month
period of time?
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If you agree to travel to LA, you will be compensated for all of your travel costs.
Do you understand?
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Are you willing to be a Surrogate for gay Intended Parents?
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Would you consider becoming a Traditional Surrogate, in which your egg would be
used and you'd become pregnant through Artificial Insemination?
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What are the ages of your children?
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Have you ever been convicted of a felony?
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Fill in Section:
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May we contact you by phone?
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Is your schedule flexible to be able to attend doctor appointments?
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Do you have any medical or psychological conditions that would interfere with pregnancy?
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Have you ever had a c-section delivery and if so, could you obtain copies of your
delivery records?
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Did you have any complications during any of your pregnancies or deliveries?
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If you did have complications, please explain.
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Upon receipt of your form and approval, how would you like the application sent
to you?
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Additional Questions:
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Why do you want to be a Surrogate?
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What form of birth control are you currently using?
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Are you currently taking ANY prescription medication?
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Additional information we should know?
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Do you Smoke Cigarettes?
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Do you use any illegal drugs or have you recently?
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Do you take anti-depressant medication?
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Please check your current relationship status?:
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If you are married or in a committed relationship is your partner supportive of
you becoming a surrogate?
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Who will provide you with support during the process, both emotionally and physically?
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If there were medical problems & the Intended Parents wanted to abort (before
18 weeks) would you agree to do so?
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Do you drive, have a valid driver's license & a working vehicle?
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Do you have Health Insurance?
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If Yes, Name of Insurance Company
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Where did you hear about us?
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Once we receive your completed form we will contact you by phone or email. If
you are more comfortable calling and speaking with us, please feel free to do so.
We would be happy to explain the process and answer any questions or address any
concerns you may have. You may reach us at: (619) 579-6510.
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