First Name: Last Name: Address: City: State: Zip Code: Email Address: Age: Height: Weight: Ethnicity: Why do you want to be a surrogate? Do you want to be a Gestational or Traditional Surrogate? Is your husband/partner supportive of your becoming a surrogate? Do you smoke? Do you drink? Are you currently taking any medications or did you stop taking any medications in the last two years? If yes give details: Have you ever given birth? What complications did you encounter during your previous pregnancies/deliveries? Have you ever participated in mental health counseling? Have you ever experienced significant emotional/physical trauma? Have you ever been diagnosed with an STD? Do you have insurance that does not have an exclusion against you being a surrogate? Are you willing/able to provide medical records? Please list any health issues you have encountered and dates: What does your family/circle of friends think about you becoming a surrogate? How did you hear about us? Security code:   * Do not enter anything in this field:

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