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Thank you for your interest in becoming a surrogate with Family Tree Surrogacy Center! Please complete the “Pre Screening" below and ensure all information provided is accurate and complete.
About You
Name
*
First
Last
Email
*
Enter Email
Confirm Email
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone Number
*
Date of birth
*
Month
Day
Year
Please add a bio about yourself.
This is something that potential intended parents like to read to learn more about you, your life and your desire to become a surrogate.
How would you describe yourself?
*
Why do you want to help a family by being their surrogate?
*
Do you speak another language?
*
Yes
No
What language(s)?
*
What is your ethnic background?
*
American Indian or Alaska Native
Asian
African American
Hispanic or Latina
Native Hawaiian or Other Pacific Islander
White
Mixed
Other:
What religion do you practice?
Christianity
Catholicism
Methodism
None
Family & Living Situation
What is your marital status?
*
Married
Engaged
Relationship (co-habitating)
Relationship (living separately)
Single
Divorced (finalized)
Divorced (in process)
Legally Separated
Separated (non-legal)
What is your partner’s name?
*
How would you describe your relationship with your spouse/partner?
*
How many biological children do you have?
*
What are the names and ages of people living with you?
*
Name
Age
Do you have reliable transportation?
*
Yes
No
Are you willing and able to travel 2 ‐ 10 times if you are reimbursed for all travel?
*
Yes
No
Do you agree to take any and all medications prescribed by the physician?
*
Yes
No
Do you and your partner agree to complete all required testing, including STD testing?
*
Yes
No
Do you and your partner agree to abstain from sexual intercourse/stimulation as instructed by the physician?
*
Yes
No
Do you agree to obtain written physician approval to travel within the U.S. after 24 weeks of pregnancy and inform the agency?
*
Yes
No
Are you currently breastfeeding/pumping?
*
Yes
No
Do you agree to not travel outside of the U.S. during this agreement and surrogacy contract?
*
Yes
No
Do you understand you are required to take medication and/or injections for up to 4 months?
*
Yes
No
Is your immediate family and friends supportive of surrogacy?
*
Yes
No
Who will be your main support during the surrogacy program?
*
Who will be able to help you with your children and daily needs in the event of physician ordered bed rest?
*
Health Information
What is your height?
*
What is your weight?
*
What is your Body Mass Index (BMI)?
*
Click here to calculate your BMI
What is your blood type?
*
I don't know
A+
A-
B+
B-
AB+
AB-
O+
O-
Do you drink alcoholic beverages?
*
Yes
No
How many on a monthly average?
*
Please describe your regular diet:
*
Are you willing to eat organic food if requested by Future Parents and reimbursed for the costs?
*
Yes
No
Do you have any known food allergies?
*
Yes
No
Please describe:
*
Do you currently take any medication?
*
Yes
No
Please provide diagnosis, medication name, dosage, and length of time on medication:
*
Have you had any surgeries or medical procedures?
*
Yes
No
Please list the year and treatment:
*
Year
Treatment
Do you currently or have a history of Depression and/or Anxiety Disorder?
*
Yes
No
Do you currently or have a history of Seizures or a Heart Condition?
*
Yes
No
Please describe:
*
Pregnancy History
How many children do you have?
*
Please list their details below.
Name
Gender (Male/Female)
Current Age
Month & Year Born
Weeks at Birth
Weight at Birth
Delivery (Vaginal/C-section)
Type (Biological/Surrogacy)
Did you have any complications during these pregnancies?
*
Yes
No
Please describe:
*
Which of the following conditions did you have during your pregnancy? Please note, not all conditions noted below mean disqualification.
*
Gestational Diabetes
Pre-Term Labor
Placenta Previa
High Blood Pressure
Pre-Eclampsia
Placenta Abruption
Bed Rest
Shortening of the Cervix
Post-Partum Depression
Hospitalization other than birth
Uterine/Ovarian Cysts
Cervical Cerclage
None of the above
Do you understand that if you had any of the above conditions, it may exclude you from continuing as a surrogate, or you may be required to obtain OB medical clearance?
*
Yes
No
Third Choice
Do you have a history of miscarriage(s)?
*
Yes
No
Please provide details:
*
Year
Gestational Weeks
Pregnancy Confirmed by OB (Yes/No)
Notes:
Have you had an elective termination?
*
Yes
No
Please provide details:
Year
Gestational Weeks
Complications (Yes/No)
Notes:
What form(s) of birth control are you currently using?
*
Birth Control Pills
NuvaRing
Diaphram
Patch
Implanon/Nexplanon
Tubal Ligation
Partner Vasectomy
Condoms
IUD
Essure
Depo Shot
None of the above
When did you begin this form of birth control? (Month / Year)
*
Have you ever been diagnosed with a sexually transmitted disease (STD)?
*
Yes
No
Please provide diagnosis, year and treatment:
*
Have you ever had an HIV screening completed?
*
Yes
No
Please give results and year:
*
Have you had any history of abnormal PAP Smears?
*
Yes
No
Please give results and date last pap smear completed:
*
Have you completed the Hepatitis B immunization?
*
Yes
No
Please provide year completed:
*
Are you willing to complete the immunization?
Yes
No
Have you completed the COVID immunization?
*
Yes
No
Are you willing to complete the immunization?
*
Yes
No
Surrogacy Preferences
Multiples are not uncommon in the context of surrogacy. It is the industry standard to place two embryos into the uterus to increase the chances of a positive pregnancy. Knowing this information, please answer the following:
Are you willing to carry a singleton?
*
Yes
No
Are you willing to carry twins?
*
Yes
No
Are you willing to carry triplets?
*
Yes
No
Please explain why not:
*
Which of the following would you be willing to be matched with?
*
Please note that intense screening is completed prior to the embryo transfer and surrogate is at no risk if surrogate has completed specific immunizations. All procedures are completed/performed in the US, no international travel is required for surrogate.
Future Parent(s) living in the US
Future Parent(s) living internationally
Future Parent(s) with children
Future Parent(s) in a biracial relationship
Future Parent that is single
Same sex Future Parents
Transgender / Non Binary Future Parent(s)
Future Parent(s) carrier(s) of Hepatitis B
Future Parent(s) who are HIV positive
Termination & Reduction
Termination and Fetal reduction can sometimes be physician recommended to ensure the safety and health of a surrogate and the baby. Physicians will not perform a termination or fetal reduction for the sex of a baby, however the physician may recommend due to a genetic abnormality.
Are you willing to allow Future Parents the choice to terminate/reduce based on personal choice?
*
Yes
No
Are you willing to terminate/reduce if medically necessary?
*
Yes
No
Are you willing to reduce Triplets to Twins, if medically recommended?
*
Yes
No
Are you willing to reduce Triplets to a Singleton, if medically recommended?
*
Yes
No
Are you willing to reduce Twins to a Singleton, if medically recommended?
*
Yes
No
Please explain why not:
*
Testing
Amniocentesis is a medical procedure used in prenatal diagnosis of chromosomal abnormalities and fetal infections, and also for sex determination, in which a small amount of amniotic fluid, which contains fetal tissues, is sampled from the amniotic sac surrounding a developing fetus, and then the fetal DNA is examined for genetic abnormalities.
Are you willing to undergo an Amniocentesis, if medically recommended?
*
Yes
No
Are you willing to undergo an Amniocentesis, if requested by Future Parents?
*
Yes
No
Employment Information
Are you currently employed?
*
Yes
No
Is your spouse/partner currently employed?
Yes
No
What is your occupation?
*
What is your hourly wage?
*
What is your work schedule (days/hours)?
*
Health Insurance Carrier: Is coverage through your employer or your partner's employer?
My employer
My partner's employer
Non applicable
Please provide a photo of you:
This should include at least one headshot and one full body picture.
Drop files here or
Select files
Max. file size: 30 MB, Max. files: 10.
Consent
I agree to the
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and consent to the collection and processing of my personal and sensitive information, including health and medical information, submitted in this form, for the purpose of evaluating my eligibility and participation in a surrogacy program.
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Future Parents
Getting Started
LGBTQ+ Parenting
California Surrogacy Laws
Surrogates
Surrogate Inquiry
Surrogate FAQs
Surrogate Requirements
Surrogate Compensation
Surrogate Mother Process
Wellness Program
Surrogate Referral Program
Payment Request
Donors
Egg Donor Application
Egg Donor Requirements
Egg Donor Compensation
Egg Donation Process
About Us
Our Professional Network
Blog
Contact
PHONE: +1 (619) 271-4093
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