Agency For Solutions

* Name

* Email

* Phone Number

City:

State you currently reside in:

Age:

Height:

Current Weight:

Weight you were at when you last got pregnant:

Number of children:

Current age of child(ren):

Length of time carried in weeks for each pregnancy:

How long did it take to conceive?

Number of c-sections, please state with which child?

Please list any complications with any of your pregnancies (high blood pressure, preclampsia, placenta previa, diabetes, etc.)

When was your last pap smear? Was it normal?

Have you ever had an abnormal pap smear – if so, when and what was the result.

Current method of birth control:

Have you had any tattoos or piercings in the last year?

Single or married?

Please describe your support system:

Will you be willing to travel out of state for an initial medical evaluation and then embryo transfer?

Have you ever been a Surrogate before?

If so, how many times?

Why do you want to be a Gestational Surrogate?

Are you open to selective reduction (in the case of triplets or more) and termination for chromosomal abnormalities? (If you are unsure please say "not sure".)

Do you have insurance that will cover a surrogacy pregnancy? (If you are unsure please say "not sure".)