Surrogate Application Before Proceeding* I have reviewed the Surrogate Qualifications on our Gestational Carrier page before starting your application.Name* First Middle Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Can we leave a message at the above number?*YesNoEmail* Enter Email Confirm Email You will receive a confirmation email. Please check your inbox often. Preferred Method of Contact*PhoneEmailAge*You must be between 21 and 40 to apply. Height*Weight*Marital Status*Single (never married)Married (legally married and currently together)Married but separated (not living together)DivorcedWidowedIn a committed relationship (not legally married)Legally married to one person but in a relationship with anotherOtherPlease explain:Are you a US citizen or permanent resident of the US?* US Citizen Permanent Resident Neither Are you currently employed?* Yes No Please list occupation:*Disclosure Acknowledgment I acknowledge that all health history I provide in this application must be accurate and complete. I understand that my full medical records will be requested and reviewed, including details of all past pregnancies, deliveries, miscarriages, and any other significant health events. I understand that any inconsistencies between my application and my medical records, especially related to my pregnancy history, may affect my eligibility to move forward.Number of Children*You must have given birth to and parented at least one child in order to apply.Have you been a surrogate before?* First-time surrogate Experienced surrogate Number of surrogate deliveries:*Total number of C-Sections:*Have you had any complications with pregnancy or delivery? (Check all that apply)* Premature Birth Still Birth Miscarriage Physician Ordered Rest Gestational Diabetes Toxemia/Preeclampsia (High Blood Pressure) Ectopic pregnancy Placenta Previa Intrauterine Growth Restriction (IUGR) Meconium (baby’s first stool) in amniotic fluid Other issues doctors were concerned about during your pregnancies: or deliveries: None Please list complication(s)*Have you ever had an abnormal Pap smear?* Yes No If yes, please explain:*Do you have any existing medical conditions?* Yes No If yes, please explain:*Are all of your immunizations up to date (measles, mumps and rubella (MMR); chicken pox; and hepatitis B)?*YesNoWhat are you missing?*Have you been vaccinated for COVID?*YesNoMost IVF doctors require COVID vaccination to qualify as a surrogate. Are you willing to be vaccinated if requested by the intended parent or their doctor?*YesNoDo you have a history of mental illness?* Yes No Do you smoke or vape any substance?* Yes No Does anyone in your household smoke or vape any substance?* Yes No If yes, please explain:*Do you drink alcohol?* Yes No Occasionally Do you or your spouse/partner have a history of substance abuse?* Yes No If yes, please explain:*Do you or your spouse/partner have a criminal history?* Yes No Who is your current health insurance provider?*Do you currently receive any financial support from the government that is not related to military benefits? (i.e. housing or food assistance, Medicaid, etc.)* Yes No You must be financially secure and should not be on any government financial assistance including welfare, public housing and section 8.If yes, please explain:*Do you have a driver's license?* Yes No Do you have your own car?* Yes No Why are you interested in becoming a surrogate?*Have you applied to any other surrogacy agencies, either now or in the past?* Yes No If yes, please list the agency/agencies:*Have you ever been disqualified or turned away by another surrogacy agency or fertility clinic?* Yes No If yes, please explain:*How did you hear about Western Surrogacy?*InstagramFacebookGoogle/Search EngineReferred by SomeoneOtherWho referred you?*By checking this box, I consent to receive calls, texts, and emails from Western Surrogacy about services I have inquired about. I agree to the Privacy Policy and to receive other communications.* I agree to the receive other communications by Western Surrogacy.
