SURROGATE APPLICATION このフォームに入力するには、ブラウザーで JavaScript を有効にしてください。 個人情報 氏名（名、中、姓） *Primary Race *生年月日 * 住所 住所住所1住所2市区町村--- state を選択 ---アラバマ州アラスカ州アリゾナ州アーカンソー州カリフォルニア州コロラド州コネチカット州デラウェア州コロンビア特別区フロリダ州ジョージアハワイアイダホ州イリノイ州インディアナアイオワ州カンザス州ケンタッキールイジアナ州メイン州メリーランド州マサチューセッツ州ミシガン州ミネソタ州ミシシッピー州ミズーリ州モンタナネブラスカ州ネバダ州ニューハンプシャー州ニュージャージー州ニューメキシコ州ニューヨークノースカロライナ州ノースダコタオハイオ州オクラホマ州オレゴン州ペンシルベニア州ロードアイランド州サウスカロライナ州サウスダコタ州テネシー州テキサス州ユタ州バーモント州バージニア州ワシントン州ウェストバージニア州ウィスコンシン州ワイオミング州都道府県/州郵便番号 連絡先 電話 *電子メール * その他 高さ *重量 * BMI *職業Current Relationship StatusHow many years have you been together?:Name of partner/spouse(First, Middle, Last)What is your level of education?Do you have any religious or spiritual views?Are you able to attend all local appointments? *はいいいえAre you actively parenting at least one of your own children? *はいいいえWhat is your main source of income? *How soon would you like to begin your Surrogacy journey? *Right away6 months1 yearHave you ever applied to any other agencies as a surrogate or egg donor? (if yes what agency?) *はいいいえName of AgencyAre there any other people residing in your home other than your children? or your partner? *はいいいえAre you able to travel out of state for 2-3 days? If travel expenses including childcare and lost wages are reimbursed? *はいいいえDo you have an existing health insurance policy? *はいいいえIf yes, who is your insurance provider? Background Do you drink alcoholic beverages? *はいいいえIf so how often?Have you or your partner ever been investigated by governmental child protective agency? *はいいいえDo you or your partner currently have any legal cases or claims pending? *はいいいえIf Yes, please explainHave you or your partner ever been involved in any lawsuit? *はいいいえIf Yes, please explainHave you ever used illicit drugs (marijuana, cocaine, methamphetamines)? *はいいいえWhen was the last time? (please note that you will be tested)Are you exposed to any second-hand smoke at home or at work? *はいいいえHave you or your partner ever been arrested? (including DUI arrests) *はいいいえIf Yes, please explain and date Medical/Reproductive History Have you ever been a surrogate or egg donor before? *はいいいえIf yes, how many times?Under what circumstances would you consider termination of pregnancy? (I.E. medical advisement, selective reduction, sever abnormalities?) *How many babies are you willing to carry during this surrogacy journey? *How many biological children do you have? *Are all of your children living with you currently?はいいいえDo you have legal custody of your children?はいいいえDo you plan on having more children of your own?はいいいえWhat is your current birth control method?Do you have a regular menstrual cycle? *はいいいえDo you have any past or current medical issues? *はいいいえIf yes, please explainAre you allergic to any medication? *はいいいえHave you ever been prescribed any medications in the last 5 years? *はいいいえIf yes, please explainHave you had any surgeries? *はいいいえIf yes, please list all reasons for surgery and month/year of surgery:Have you ever been diagnosed with : *TB/exposed to TB癌Irregular HeartbeatHeart Problems/Congenital Heart defectHead InjuriesThyroidProblemsSeizures貧血Genital Warts Chlamydia GonorrheaGenital HerpesHave you ever been diagnosed with Syphilis?HIVHepatitis B Hepatitis COvarian CystsHPVHave you ever had any miscarriages? This excludes any chemical pregnancies (where the heartbeat was never detected) *はいいいえHave you had any abortions? *はいいいえHave you been vaccinated for covid-19? *はいいいえ Pregnancy #1 Was this pregnancy for yourself or a surrogacy journey?MyselfSurrogacy journeyDate of deliveryWeeks of gestationAny complications?はいいいえIf yes, please explainNumber of babies delivered?Vaginal or C-section?はいいいえIf yes, please explain why?Childs Birth Weight Pregnancy #2 Was this pregnancy for yourself or a surrogacy journey?MyselfSurrogacy journeyDate of deliveryWeeks of gestationAny complications? はいいいえIf yes, please explainNumber of babies delivered?Vaginal or C-section?はいいいえIf yes, please explain why?Childs Birth Weight Psychological History Have you or your partner if applicable ever had psychological counseling? *はいいいえHave you ever been prescribed any psychiatric medications? (including anti-depressants and anti-anxiety medications) *はいいいえHave you ever been diagnosed with any of the following? *Drug or alcohol addictionAn eating disorderSchizophreniaうつ病Nervous breakdownBi-polar disorderPersonality disorderAnxietyHave you ever been hospitalized for psychiatric care? *はいいいえHave you ever attempted suicide? *はいいいえ Surrogacy Questions Base fee? *Why do you want to become a surrogate? *What would you like the Intended Parents know about you? *What kind of relationship would you like with your IP's during your surrogacy journey? (friendship, very little to NO communication) *What kind of relationship would you like after delivery? *Would you be comfortable with the IP's in the delivery room? *はいいいえWould you be willing to pump after delivery? *はいいいえAre you comfortable having the IP in the transfer room/or recording the transfer for the IP? *はいいいえName at least 3 people who your support system consist of? *Are you comfortable with injections and taking oral medication for surrogacy? *はいいいえ About you Describe your personality? *What does your daily routine consist of? *What do you do for fun? *What are your hobbies? *What is your favorite way to spend time with your family? *What is your favorite flower? *What is your favorite way to relax? *What is your favorite dessert, candy or snack food? *What is your favorite color? *What is your favorite Movie or TV show? *Favorite type of jewelry? (I.E. rings, necklaces, or bracelets?) *How did you hear about us? *写真を何枚か送っていただけますか？ * Drag & Drop Files, Choose Files to Upload 最大 5 個のファイルをアップロードできます。 123私は、上記および前述の表明が、私の情報、知識および信念の及ぶ限り、真実かつ正確であることを誓うか、確約します。Sign date *投稿する
