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Surrogate Application
Please, fill out the following application to receive more information about becoming a Gestational Carrier with Midwest Surrogacy, LLC.
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First Name
*
Your answer
Last Name
*
Your answer
Age
*
Your answer
Email
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State/Region
*
Your answer
Postal Code/Zip Code
*
Your answer
Phone Number
*
Your answer
Height
Your answer
Weight
Your answer
Sexual Orientation
Your answer
Marital Status
Your answer
Check any/all that apply
I Have Children
I Want More Children
Other:
Ages of Children
Your answer
Do you have any adopted children? If so, ages?
Your answer
Are you fostering any children? If so, ages?
Your answer
Citizenship
Your answer
Other than English, what other languages do you or your family speak and write?
Your answer
Check any/all that apply
I own a car
I have Automobile insurance
I am employed
Name of spouse or partner
Your answer
How does your partner feel about your interest in surrogacy?
Your answer
Is he/she supportive and willing to undergo any required testing?
Yes
No
Maybe
Other:
Check any/all that apply
I have health insurance
I have Maternity Coverage
What medical insurance company do you use?
Your answer
Are there any surrogacy exclusions?
Your answer
Check any/all that apply
I have been a traditional carrier before
I have been a gestational carrier before
I have been an egg donor before
When are you willing/able to start?
Your answer
Are you willing to work with: (Check any/all that apply)
Single Intended Mother
Single Intended Father
Intended Father (Couple)
Intended Mother (Couple)
Traditional Couple (Husband/Wife)
International
Inter-racial
Couple with Children
Gender Reassignment to become Man
Gender Reassignment to become Woman
How many pregnancies have you had?
Your answer
Have you had a miscarriage? If so, how many, and have you had a successful pregnancy and delivery after your last miscarriage?
Your answer
How many c-sections have you had?
Your answer
Have you had any pregnancy complications? (i.e. gestational diabetes, pre-term labor, preeclampsia, post partum depression, etc)
Your answer
Relocation: Is there any possibility of relocating to a different state in the next 18 months or during any time during the surrogacy?
Yes
No
Maybe
Other:
If relocating, please explain the circumstances, state and when.
Your answer
Are you on any state assistance? (Welfare, Medicaid, etc?)
Yes
No
Other:
Do you take any medications and/or supplements (prescription or OTC)?
Yes
No
Other:
Are you currently and/or have you ever been on medication for migraines, depression, anxiety, etc? If so, how long and how often?
Your answer
Are you still taking any of those medications?
Yes
No
Do you know your blood type?
Your answer
How did you hear about Midwest Surrogacy, LLC?
Your answer
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