SURROGATE APPLICATION 请在浏览器中启用JavaScript来完成此表单。 个人信息 姓名（名、中、姓） *Primary Race *出生日期 * 地址 地址地址 1地址第 2 行市--- Select state ---亚拉巴马州阿拉斯加州亚利桑那州阿肯色州加利福尼亚科罗拉多州康乃狄克州特拉华州哥伦比亚佛罗里达格鲁吉亚夏威夷州爱达荷伊利诺斯州印第安纳州爱荷华州堪萨斯州肯塔基州美国路易斯安那州曼恩河马里兰马萨诸塞州密歇根州明尼苏达州密西西比州密苏里蒙塔纳州内布拉斯加州内布拉斯加州新汉普郡新泽西新墨西哥纽约北卡罗莱纳州北达科他州俄亥俄州俄克拉荷马州俄勒冈州宾夕法尼亚州罗德岛州南卡罗来纳州南达科他州田纳西州德克萨斯州犹他州佛蒙特州弗吉尼亚华盛顿州西维吉尼亚州威斯康辛州怀俄明州国家邮政编码 联系信息 电话 *电子邮件 * 其他 高度 *重量 * BMI *职业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? *是没有Are you actively parenting at least one of your own children? *是没有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?) *是没有Name of AgencyAre there any other people residing in your home other than your children? or your partner? *是没有Are you able to travel out of state for 2-3 days? If travel expenses including childcare and lost wages are reimbursed? *是没有Do you have an existing health insurance policy? *是没有If yes, who is your insurance provider? Background Do you drink alcoholic beverages? *是没有If so how often?Have you or your partner ever been investigated by governmental child protective agency? *是没有Do you or your partner currently have any legal cases or claims pending? *是没有If Yes, please explainHave you or your partner ever been involved in any lawsuit? *是没有If Yes, please explainHave you ever used illicit drugs (marijuana, cocaine, methamphetamines)? *是没有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? *是没有Have you or your partner ever been arrested? (including DUI arrests) *是没有If Yes, please explain and date Medical/Reproductive History Have you ever been a surrogate or egg donor before? *是没有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?是没有Do you have legal custody of your children?是没有Do you plan on having more children of your own?是没有What is your current birth control method?Do you have a regular menstrual cycle? *是没有Do you have any past or current medical issues? *是没有If yes, please explainAre you allergic to any medication? *是没有Have you ever been prescribed any medications in the last 5 years? *是没有If yes, please explainHave you had any surgeries? *是没有If yes, please list all reasons for surgery and month/year of surgery:Have you ever been diagnosed with : *TB/exposed to TB癌症Irregular HeartbeatHeart Problems/Congenital Heart defectHead InjuriesThyroidProblemsSeizures贫血Genital Warts Chlamydia GonorrheaGenital HerpesHave you ever been diagnosed with Syphilis?HIV / 爱滋病代孕Hepatitis B Hepatitis COvarian CystsHPVHave you ever had any miscarriages? This excludes any chemical pregnancies (where the heartbeat was never detected) *是没有Have you had any abortions? *是没有Have you been vaccinated for covid-19? *是没有 Pregnancy #1 Was this pregnancy for yourself or a surrogacy journey?MyselfSurrogacy journeyDate of deliveryWeeks of gestationAny complications?是没有If yes, please explainNumber of babies delivered?Vaginal or C-section?是没有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? 是没有If yes, please explainNumber of babies delivered?Vaginal or C-section?是没有If yes, please explain why?Childs Birth Weight Psychological History Have you or your partner if applicable ever had psychological counseling? *是没有Have you ever been prescribed any psychiatric medications? (including anti-depressants and anti-anxiety medications) *是没有Have you ever been diagnosed with any of the following? *Drug or alcohol addictionAn eating disorderSchizophrenia抑郁症Nervous breakdownBi-polar disorderPersonality disorderAnxietyHave you ever been hospitalized for psychiatric care? *是没有Have you ever attempted suicide? *是没有 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? *是没有Would you be willing to pump after delivery? *是没有Are you comfortable having the IP in the transfer room/or recording the transfer for the IP? *是没有Name at least 3 people who your support system consist of? *Are you comfortable with injections and taking oral medication for surrogacy? *是没有 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? *能给我们发几张你的照片吗？ * Drag & Drop Files, Choose Files to Upload You can upload up to 5 files. 123我宣誓或确认，就我所知、所晓、所信，上述及前述陈述均属真实无误。Sign date *提交
