Surrogacy Agency in San Diego | Great Beginnings Surrogacy Services

Thank you for taking the time to complete the GBSEDS Full Surrogate Application. We look forward to receiving your information and contacting you about next steps!

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SURROGATE APPLICATION

DEMOGRAPHIC INFORMATION

First Name *

Last Name *

Birthdate (MM/DD/YYYY) *

Email *

Address *

Address

City

State/Province

Zip/Postal

Country

Cell Phone *

Age *

Height (Feet and Inches) *

Weight (LBS) *

Blood Type *

Maternal Ancestry (where does your Mom’s people come from?): *

Paternal Ancestry (where does your Dad’s people come from): *

What Language(s) Do You Speak Other Than English: *

Marital Status *

Length of Time *

Religion *

Practicing? *

Number of Adults Living in Your Household (In Addition to Yourself): *

For Each Adult, Please Provide First Name, Last Name and Relationship to You *

What is your Partner/Spouse’s Occupation? *

HEALTH INSURANCE INFORMATION

Do You Have Medical Insurance? *

Name of Medical Insurance Company *

Effective Date: *

Premium Amount: *

Type of Coverage: *

Is This Policy Issued Through an Employer? *

Whose Employer Issued This Policy? *

Does Your Insurance Cover Surrogacy? *

PERSONAL HISTORY

How Many Children Do You Have? *

Number of Children Living In Your Household: *

Please List Your Children’s Full Names and Ages *

Please describe all your children’s current health and any history of health problems: *

Are You Currently Receiving Any Government Assistance (e.g., Welfare, Disability, Food Stamps, etc.)? *

Please Provide Further Details: *

SURROGACY EXPERIENCE:

Are You a? *

Were Your Transferred Embryos *

Number of Embryos Transferred *

Number of Babies Born *

Delivery Dates (MM/DD/YYY): *

Did You Require Physician-Ordered Bed Rest? *

For Each Instance of Physician-Ordered Bed Rest During Surrogate Pregnancy, List Extent (Moderate, Complete, Etc.), Length of Time and Under What Circumstances: *

Did You Apply For/Require Disability During Your Surrogate Pregnancy? *

For Each Instance of Being Placed on Disability During Surrogate Pregnancy, List Extent (Moderate, Complete, Etc.), Length of Time and Under What Circumstances: *

PERSONAL INFORMATION:

Please Explain Your Reasons for Choosing to Become a Surrogate: *

Please Describe Your Personality and Character: *

Are You in a Stable Household and Living Situation at This Time? *

If No, Please Explain *

SUPPORT SYSTEMS

Please describe the kind of relationship you have with and the kind of support during your surrogacy you expect from the following people:

Partner/Spouse: *

Children: *

Parents: *

Friends & Co-Workers: *

Did You Willing to Attend Support Group Meetings with Other Surrogates? *

If No, Please Explain *

GENERAL INFORMATION

What Qualities are Most Important to You in Choosing Intended Parents to Help Through Surrogacy? *

What Relationship do You Want with Intended Parents During the Conception and Pregnancy? *

Are You Willing for the Intended Parents to Attend Obstetrical Appointments with You? *

If No, Please Explain: *

If the Intended Parents Cannot be Present and Ask for an Agency Coordinator to Do So, Are You Willing to Allow Us to Attend Your Appointments with You? *

If No, Please Explain: *

Are You Willing for the Intended Parents to be Present at the Birth? *

If No, Please Explain: *

What Type of Relationship do You Want with Intended Parents After the Birth? *

How Can You Assure the Intended Parents That You Will Not Back out of Your Commitment to Help Them at Any Time After Being Matched? *

Did You Willing Carry to Multiples (e.g., Twins, Triplets, etc.)? *

Please Explain: *

Would You Undergo a Selective Reduction Procedure if a Multiple Pregnancy is Confirmed? *

If No, Please Explain: *

If There is a Medical Problem with the Pregnancy or With the Child(Ren) 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 Explain Your Answer: *

Are You Willing to Travel Outside Your County or State or Country to a Center Chosen by the Intended Parents? *

If No, Please Explain: *

Please Explain Any Special Desires or Requests Regarding Your Obstetrical Care and Delivery Plan for the Birth? *

Do You Have Any Special Needs Regarding Child Care? *

Are You Willing to Provide Expressed Breast Milk for the Baby You Will Carry (For a Set Period of Time; For Example, One to Two months After Delivery)? NOTE: You Will Receive Additional Compensation For This Service (at Least $600/Month). *

REPRODUCTIVE HISTORY

Age of Onset of Menstrual Cycle: *

Do You Have Regular Periods? *

Please Explain: *

Cycle Length (How Many Days From Your Period Stopping Until It Starts Again): *

Days of Flow (Number of Days from Period Starts Until Period Ends) *

Is Your Flow *

Do You Have Pain or Cramps? *

If Yes, Please Explain: *

Do You Presently Use Birth Control (How You Keep From Getting Pregnant)? *

If No, Please Explain: *

Please Indicate the Type of Birth Control You Are Currently Using: *

Please Indicate the Type of Birth Control You Are Currently Using:

Are You Currently Breastfeeding? *

How Often? By What Date Do You Plan to Stop? *

Have You Ever Had a Miscarriage/Abortion? *

By Date, Please Describe the Circumstances of Each Individual Miscarriage/Abortion: *

How Many Pregnancies Have You Had (Excluding Abortions/Miscarriages)? *

By Date, Please List All Pregnancies Resulting in Delivery, Beginning with Date of Delivery (MM/DD/YYYY), Weight (Pounds & Ounces), Gestational Age (Weeks and Days), Sex, Method of Delivery (Vaginal/C-section), Hours in Labor, and Any Complications. *

By Date, Please Describe Each Individual Pregnancy Complication (e.g., Premature Birth, Stillbirth, Pre-Term Labor, Gestational Diabetes, Placentia Previa, Home Monitoring, etc.) or anything exceptional about any of your pregnancies: *

Did You Require Any Bed Rest During Any of Your Pregnancies? *

For Each Instance of Bed Rest During Your Own Pregnancy, List Extent (Moderate, Complete, Etc.), Length of Time and Under What Circumstances: *

Were You on Disability During Any of Your Pregnancies? *

For Each Instance of Being Placed on Disability During Your Own Pregnancy, List Extent (Moderate, Complete, Etc.), Length of Time and Under What Circumstances: *

Have You Ever Taken More Than 6 Months to Become Pregnant? *

Please Explain: *

Have You Ever Undergone Any Fertility Treatments to Become Pregnant? *

Please Explain: *

Did You Have Physician-Ordered Bed Rest During Any of Your Pregnancies? *

For Each Instance of Physician-Ordered Bed Rest During Surrogate Pregnancy, List Extent (Moderate, Complete, Etc.), Length of Time and Under What Circumstances: *

Date of Your Most Recent OB/GYN Appointment *

Date of Your Most Recent Pap Smear *

Pap Smear Results *

Pap Smear Results

Please Explain: *

Have You Ever Had an Abnormal Result on a Pap Smear? *

Please Explain, Including Date(s), Treatment(s) and Outcomes: *

MEDICAL INFORMATION

The following section includes questions along a wide spectrum of issues related to reproductive health care.

Have You Ever Received Intravenous Pituitary-Derived Human Growth Hormone? *

Date(s): *

Have You Received Non-Therapeutic Injected Drugs Within the Last 5 Years? *

Dates(s): *

Have You Ever had a Blood Transfusion? *

Dates(s): *

Have You Been Exposed in Any Capacity to Infected Blood in the Last 12 Months? *

Dates(s): *

Have You Had Any Body Piercings in the Last 6 Months? *

Dates(s): *

Have You Had Any Tattoos in the Last 6 Months? *

Dates(s): *

Have You Been Bitten by an Animal Suspected of Rabies Within the Last 6 Months? *

Dates(s): *

Do You/Have You Ever Had a Sexual Partner Who Takes Injectible Drugs? *

Dates(s): *

Have You Engaged in Prostitution at Any Time since 1977? *

Dates(s): *

Have You Been Sexually Involved with Anyone Known to Have a Hepatitis Infection? *

Dates(s): *

Have You Had Close Contact With Anyone Known to be HIV Positive? *

Dates(s): *

Have You Ever Received Intravenous Factor VII or Factor IX concentrate Which Was Not Heat-Treated or Otherwise Virally Inactivated? *

Dates(s): *

Have You Ever Been Arrested/Been an Inmate in a Correctional Facility For More Than 72 Hours Within the Last 12 Months? *

Dates(s): *

Have You Been Exposed to Radiation or Toxic Chemicals, Such as Lead, Mercury or Gold? *

Dates(s) & Which Substances Were You Exposed to *

Have You Traveled Outside of the United States in the Past Year? *

Where Did You Go and For How Long? *

Have You Ever Had an HIV/AIDS test? *

Please Provide Date(s) of the Test(s) and the Results: *

Do You Smoke or Use Tobacco in Any Form, Including Vaping? *

Please Explain: *

Does Your Partner/Spouse Smoke Cigarettes? *

Please Explain: *

Do You Drink Alcoholic Beverages? *

Please Explain: *

Do You/Have You Ever Used Any Illegal Drugs? *

Which Drugs? For How Long?: *

Do You Take Any PRESCRIPTION medications? *

Please Explain: *

Do You Take Any Over the Counter medications? *

Please Explain: *

Have You Had Any Therapy With a Psychotherapist, Psychiatrist, or Any Other Mental Health Professional? *

Please Explain: *

Please List Any Past or Current Medical Problems: *

Allergies? *

Please List: *

Have You Had Any Surgery? *

Please List Type of Surgery, Date, Where and Type of Anesthesia Used (Local/General): *

Have You Had Group Beta Strep (GBS)? *

Dates(s): *

Have You Had Genital Warts? *

Dates(s): *

Have You Had Hemorrhoids? *

Dates(s): *

Have You Had Ovarian Cysts? *

Dates(s): *

Have You Had PID (Pelvic Inflammatory Disease)? *

Dates(s): *

Have You Had Uterine Fibroids? *

Dates(s): *

Have You Had Varicose Veins? *

Dates(s): *

Have You Had Chicken Pox? *

Dates(s): *

Have You Had German Measles? *

Date(s): *

Have You Had Polio? *

Date(s): *

Have You or Your Partner/Spouse Been Diagnosed With Hepatitis B? *

Who Has Been Diagnosed With Hepatitis B? *

Date(s): *

Have You or Your Partner/Spouse Been Diagnosed With Hepatitis C? *

Who Has Been Diagnosed With Hepatitis C? *

Date(s): *

Have You or Your Partner/Spouse Been Diagnosed With Herpes? *

Who Has Been Diagnosed With Herpes? *

Date(s): *

Have You or Your Partner/Spouse Been Diagnosed With HIV/AIDS? *

Who Has Been Diagnosed With HIV/AIDS? *

Date(s): *

Have You or Your Partner/Spouse Been Diagnosed With Gonorrhea? *

Who Has Been Diagnosed With Gonorrhea? *

Date(s): *

Have You or Your Partner/Spouse Been Diagnosed With Syphilis? *

Who Has Been Diagnosed With Syphilis? *

Date(s): *

EMERGENCY CONTACT INFORMATION – In the unlikely event you require emergency treatment, we will call each number on your list until we reach a “live” person. If unable to reach a live person, we need the full addresses of all your contacts so the police can go to the address to send your emergency contact person to your side ASAP.

EMERGENCY CONTACT PERSON – First and Last Name: *

Relationship to You: *

Address *

Address

City

State/Province

Zip/Postal

Cell Phone *

ALTERNATE CONTACT PERSON #1 – First and Last Name: *

Relationship to You: *

Address *

Address

City

State/Province

Zip/Postal

Cell Phone *

ALTERNATE CONTACT PERSON #2 *

Relationship to You: *

Address *

Address

City

State/Province

Zip/Postal

Cell Phone *

ALTERNATE CONTACT PERSON #3 *

Relationship to You: *

Address *

Address

City

State/Province

Zip/Postal

Cell Phone *

You’ve done it! Please sign, click “Submit” and you will be on your way!

CERTIFICATION: I hereby certify that I have answered the above questions honestly and accurately to the best of my ability. *

Signature *

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