Gestational Carrier Initial Intake Form

First Name

Last Name

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Street Address

City

Country

State

Zip Code

Phone Number

Best time to contact you

Email

Are you a US Citizen?

Are you legally residing and able to work in the United States?

Height

'

"

Weight

lbs

Are you currently on any mood stabilizers, antidepressants, or antipsychotics?

Is this a medication that both you and your doctor are comfortable discontinuing before you begin your surrogacy journey?

Do you currently smoke or vape (including e-cigarettes)?

Do you use any illegal drugs?

Have you had at least one previous successful pregnancy and birth?

How many live births have you had?

How many C-sections have you had?

Have you previously been a surrogate?

How many times?

How did you hear about us?

Name of person who referred you.

Name of clinic that referred you.

Please provide referral source.