Gestational Surrogate Applicant Questionnaire

It looks like you could be a great candidate for surrogacy! Please complete the rest of our application.

Address

Street Address Address Line 2 City State/Region/Province Postal / Zip Code

How do you describe your ethnicity? *

What is your marital status? *

What is your spouse/partner's first name? *

What is your spouse/partner's last name? *

Please provide your spouse's email *

Must be a different email from your own.

Spouse/partner's date of birth *

MM/dd/yyyy

How did you find Southern Surrogacy? *

Please upload a copy of your driver's license *

Please upload a picture of yourself *

Height *

Weight (lbs) *

Are you currently under a doctor's care for any physical or emotional condition? If so, please describe. *

Have you had a Covid vaccine? *

Did you get a flu vaccine in the most recent flu season? *

Provide the name of your current OB and the name of the practice *

What is the name of the hospital where you would deliver a child? *

Have you been a surrogate before? *

Have you applied with other surrogacy agencies? *

Have you traveled outside of the US in the past year? *

Please describe your recent foreign travel. *

Do you have plans to travel outside of the US in the next year? *

Please describe your travel plans. *

Please describe the reason why you would or would not terminate a pregnancy. *

What sort of Intended Parents are you looking for? *

Are you employed outside of the home? *

What is the name of your employer? *

What is your title or position in your employment? *

How long have you worked at your current job? *

What is your current salary/wage? *

Do you have medical insurance? *

What is the source of your medical insurance? *

What is the name of your insurance policy? *

Do your children have medical insurance? *

Who is the provider of your children's medical insurance? *

Your Pregnancies