Surrogate Profile Surrogate Profile Surrogate Profile 2026 Step 1 of 7 14% First NameSurrogateInsert Profile Pictures HereMax. file size: 1 GB. Base Fee for SingleAdditional Twin FeeStatusSelectAvailableUnavailableRepeat Donor or SurrogateHealth Insurance CompanyCity, State, Country City State / Province / Region AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Are you willing to travel out of state for up to 5 days? Yes No Are you willing to travel out of country for 7-10 days? Yes No Do you have a valid passport with at least 6 months until it expires? Yes No Are you financially stable?Your Month and Year of Birth MM slash DD slash YYYY Your HeightYour WeightYour BMI (online calculator)Do you have reliable transportation to and from medical appointments?Do you have a stable and safe place of residence?Education/EmploymentDid you graduate high school or receive a GED?Have you attended a trade school, college, or university?Highest level of education completion?Current OccupationDescription of duties, days and hours worked, hourly rate:Do you have plans on furthering your education? Please give details:What are your career and family goals? Spouse/Live-in PartnerAre you currently legally married?Date of marriage MM slash DD slash YYYY Number of DivorcesDate(s) of Divorce(s)Spouse/Partner First NameSpouse/Partners Month and Year of Birth MM slash DD slash YYYY Husband/Partner's OccupationDescription of job duties, days and hours worked, hourly rate MedicalEthnicityRace/National OriginBlood TypeBMISexual OrientationDate of last OBGYN visit MM slash DD slash YYYY Date of last Pap Smear MM slash DD slash YYYY Results Good Negative Do you have regular monthly menstrual cycles?At what age did you have your first cycle?How many days are you cycle?(Surrogates will be required to take a birth control pill while waiting to match. Any surrogate that has used the depo injection must wait 9 months from their last shot to match.) Are you using birth control?What Method?For how long?Any complications experienced with this method?Has your weight changed dramatically in the last five years for reasons other than pregnancy?Please explain whyAre you on any special diet?Have you received any tattoos in the last year? If so, what date?Have you received any tattoos in the last year? If so, what date? Yes No Have you received any tattoos in the last year? If so, what date? MM slash DD slash YYYY Have you received any piercings in the last year? If so, what date? Yes No Have you received any tattoos in the last year? If so, what date? MM slash DD slash YYYY Please describe any medical diagnoses/problems you may have/hadDo you take vitamins/supplements? If so, whichPlease list any medications and dosage you are currently takingPlease list all other prescription medication, dates taken, reason for prescription, and dosage taken over the last year:Please list any hospitalizations, surgeries, or plastic surgeries you have had and the dates and reason each event occurredHave you or any of your partners ever had a blood transfusion?Please explainSTD HistoryAre you currently sexually active with anyone other than your partner listed on this application?Please explainHave you or your husband or partner or any past sexual partners ever been diagnosed with the following (please include approx. date of diagnosis, treatment used, current status) Chlamydia Syphilis Gonorrhea HPV Genital Herpes Hepatitis B Hepatitis C Ovarian Cyst PID HIV or AIDS Have you or your husband or partner or any past sexual partners ever been diagnosed with the following (please include approx. date of diagnosis, treatment used, current status)Vaccine StatusHave you received any vaccines in the last 5 years? If so, please let us know which vaccine and what date.Have you received the COVID vaccine? If so, what date and which band? Please include booster shots.If your clinic requires any vaccines (not including COVID), are you willing to vaccinate?If your clinic requires up to date COVID vaccination, are you willing to vaccinate?Are you willing to follow CDC recommendations for any current public health concerns? Children/Pregnancy/BirthTotal Number of PregnanciesHave you ever placed a child for adoption Yes No Number of children resulting from prior surrogacy journeysNumber of biological childrenNumber of children living in your homeNumber of Miscarriages (please include approx. date, how many weeks gestation, and any known reason)Number of Abortions (please include approx. date, how many weeks gestation, and reason)Pregnancy #1Date of Birth MM slash DD slash YYYY Months trying to conceiveBirth WeightC-section or VaginalWeeks Gestation At DeliveryInduced or Spontaneous LaborPlease select any complications that occurred(i.e. premature birth (diagnosis required), bed rest and reason/diagnosis, gestational diabetes with treatment, placenta previa/did this resolve and when, etc.)Pregnancy #2Date of Birth MM slash DD slash YYYY Months trying to conceiveBirth WeightC-section or VaginalWeeks Gestation At DeliverInduced or Spontaneous LaborPlease select any complications that occurred(i.e. premature birth (diagnosis required), bed rest and reason/diagnosis, gestational diabetes with treatment, placenta previa/did this resolve and when, etc.)Pregnancy #3Date of Birth MM slash DD slash YYYY Months trying to conceiveBirth WeightC-section or VaginalWeeks Gestation At DeliverInduced or Spontaneous LaborPlease select any complications that occurred(i.e. premature birth (diagnosis required), bed rest and reason/diagnosis, gestational diabetes with treatment, placenta previa/did this resolve and when, etc.)Pregnancy #4Date of Birth MM slash DD slash YYYY Months trying to conceiveBirth WeightC-section or VaginalWeeks Gestation At DeliverInduced or Spontaneous LaborPlease select any complications that occurred(i.e. premature birth (diagnosis required), bed rest and reason/diagnosis, gestational diabetes with treatment, placenta previa/did this resolve and when, etc.)Pregnancy #5Date of Birth MM slash DD slash YYYY Months trying to conceiveBirth WeightC-section or VaginalWeeks Gestation At DeliverInduced or Spontaneous LaborPlease select any complications that occurred(i.e. premature birth (diagnosis required), bed rest and reason/diagnosis, gestational diabetes with treatment, placenta previa/did this resolve and when, etc.)Surrogates and Egg Donors must have had a physical within the past 12 months to include: pap smear, CBC, thyroid, STD lab work. This must be received with your OB Medical Clearance Form. Drug and Alcohol UseDo you smoke or vape?How many cigarettes per day?How frequently do you vape? What substance do you vape?(Please note that Egg Donors and Surrogates may not have smoked or vaped within 6 months from starting the matching process and must not smoke or vape during the contracted period with us.)Do you drink alcoholic beverages?How Often? (per day/week, etc.)(Please note that once you start your IVF medication before a transfer and while pregnant you may not drink alcohol.)Do you understand that you may not drink alcohol while pregnant?Are you currently or in the past 12 months have you used marijuana?If so, what dates and how often. What date did you stop.(Please note Surrogates must not have used marijuana within 6 months of applying and must note use while contracted to become a surrogate.)Are you currently using illicit drugs?Have you ever used illicit drugs?Please indicate what drug, when the use occurred, when the use stopped, and frequency of useDo you understand that while participating in the surrogacy program, you may not smoke, vape, use nicotine, marijuana, or any illicit drug?Been in a substance abuse program?Please Explain Legal FilingsHave you or your spouse/partner everFiled for bankruptcy?Please Explain, to include year:Been arrested?Please Explain, include charge(s), year, and outcomeBeen involved in any legal cases with you as the defendant, or any that are pending?Please Explain, include charges, year(s), and outcome Psychological HealthHave you ever been admitted to a psychiatric facility?Please Explain, include year(s) and diagnosesHave you ever been physically abusedHave you ever been sexually abused, if yes, by whomHave you ever had thoughts or attempted suicide? If so, what year(s) for each respectively?Do you suffer from bipolar disorder?Do you suffer from Anxiety Issues?Have you ever been sexually assaulted?Have you ever had any psychological counseling for the above-mentioned, if yes, please include the approx. dates attended?Have you or your spouse/partner ever received counseling for anything not mentioned above, if so, please give reason and approx. dates?Traits and Personal CharacteristicsPlease describe your personality and characterWhat do you like to do in your spare time?Do you practice any organized religion? If so, which one?What is your philosophy on life?Support SystemWhat kind of support do you expect from the following people (Please detail who is in your support system and their relation to you, as well as what type of support they give to you and how frequently)Your spouse/partner?Your parents?Friends/co-workers?Matching with Intended ParentsWhich type of surrogacy are you interested in?Gestational (not genetically your child)Traditional (uses your genetic egg)Do you understand that a surrogacy journey can take a 12–18-time frame?Why do you want to be a Surrogate?Briefly explain your understanding about how the Surrogate program works.Are you willing to pump breastmilk and ship at the expense of the Intended Parent?If you have children, what do you plan to tell your children about you being a Surrogate?What qualities would you consider most important in choosing a Recipient Couple?Please indicate who you are NOT willing to work withAre you willing to work with an intended Family that prefers limited or no contact during conception and pregnancy?Will you work with an Intended Parent that has HIV (suppressed)? Please note that sperm are washed, and this will require you to take additional medication to ensure your safety.Will you work with an Intended Parent that is hepB positive? Please note that sperm are washed to protect you as well as a hepB vaccine will be required.Will you work with single Intended Parent?Will you work with a gay Intended Parent?Would you like to meet the Intended Family either in person or by video chat?What contact would you like during the process with the Intended Parents, if any?What kind of relationship do you want to have with your Intended Family after birth, if any?How would you respond if the child wanted to see you at some time later in his or her life?Embryo Transfer and Surrogate PregnancyWhat is the maximum number of embryos you are willing to have transferred to you?Are you willing to carry fraternal twins?Are you willing to carry identical twins?Are you willing to carry triplets?Would you undergo a selective reduction procedure if a multiple pregnancy is confirmed?Would you undergo a selective reduction procedure if a multiple pregnancy is confirmed?If there is a medical problem with the pregnancy, or with the child you are carrying as a surrogate and the Intended Parents want to consider abortion; would you allow them to make that decision based on the advice of their physician and personal beliefs?Please explainDo you and your partner understand that, unless you have had a tubal ligation or your partner has had a vasectomy, you must agree to abstain from sexual activity while undergoing medical treatment and participating in this program?What message would you like to pass on to the Intended Family considering this profile?
