Formulario de Gestantes

SURROGATES

To participate in our surrogacy program you have had complications in previous pregnancy or birth, have regular periods, no history of any disease genetic or sexual transmission, not have a history of any serious medical condition or ongoing, never had positive test results for HIV or AIDS, and have reliable transportation.
They are not admitted to the program, women who have used drugs, whether smokers or abuse of alcoholic beverages.
You must have a weight proportional to your height and BMI within healthy standards.
Commitment into our program includes pregnant obligation to attend appointments for physicals and psychological treatment during and after pregnancy.
Your personal information is protected, is strictly confidential and have adopted security measures in accordance with international standards. Please enter your details below:

Be prepared to pass a medical examination with your partner. Show that you are emotionally and psychologically stable. Have reliable transportation and Be financially stable and not receive financial assistance from the State.

Tell us about you.:
First Name:		*
Second Name:		*
Maiden name:
Address:		*
Zip Code:		*
City:		*
State:		*
Country:		*
Email:		*
Phone:		*
Date of birth:		*
Age:		*
Height:		*
Weight:		*
Ethnicity:		*
Civil Status:		*
Smoker?:		*
Health insurance?:		*
Name of the Insurance Company:
Have u been surrogate before?:	Yes No	*
How did u hear about us?:
Level of Education:		*
My health is:		*
Blood Group:		*
Number of childs:		*
Ready to be surogate for:	All. Only Heterosexual couples. Gay couples. Individuals.	*
Willing to travel?:	Yes No Depende	*
Do u hava a Passport?::	Yes No	*
Hair color:	Black hair Brown hair Blond hair Auburn hair Chestnut hair Red hair Other	*
Why do you want to be a surrogate?:		*
Eye color::	Amber Blue Brown Gray Green Hazel Red and violet	*
What is your U.S. citizenship status?:	U.S. Citizen Green Card Visa I do not have any of above
If you have Visa, When does it expires?:
Do you have a religion? Please detail:
What is your occupation?:
Are you a member of the US military?:	Yes No
If you have any partner or spouse, what is his/her name? :
What is your partner occupation? :
Is your partner a member of the U.S. military?:	Yes No
If your partner have health insurance, please detail:
Do you anticipate any change to your health insurance in the next year?:	Yes No
Have you ever been arrested?:	Yes No
Have your partner ever been arrested?:	Yes No
Would you terminate the pregnancy if:
Your health was at risk:	Yes No
If the fetus has Down syndrome and the intended parents chose to terminate the pregnancy:	Yes No
If has any other chromosomal issue and the intended parents chose to terminate the pregnancy?:	Yes No
Would you be willing to reduce to do reduction if requested by the Parents or doctor?:	Yes No
Do you have history of smoking during pregnancy?:	Yes No
Have you ever tested positive for HIV?:	Yes No
Do you drink alcohol excessively or use drugs of any kind?:	Yes No
Have you or have anyone in your household been convicted a felony?:	Yes No
Is any member of your household a registered sex offender?:	Yes No
if you've had C-Sections indicate how many:
if you've had miscarriages indicate how many:
Has any member of your household ever been diagnosed with any mental issue. Detail please:
Have you even been diagnosed with any mental issue? Please detail:
Taken any anti- depressants, anti- psychotics, or anti-anxiety medications in the past six months?:	Yes No
Taken any anti- depressants, anti- psychotics, or anti-anxiety medications during pregnancy?:	Yes No
Have you ever have a psychiatric hospitalization?:	Yes No
Are you financial stable?:	Yes No
Are you receiving any additional forms of government financial assistance?:	Yes No
Have you ever had varicella?:	Yes No
Have you previously received the varicella vaccine?:	Yes No
Have you been vaccinated for measles, mumps and rubella (MMR)?:	Yes No
Have you ever been immunized for Hepatitis B?:	Yes No
If No, are you willing to be vaccinated prior to becoming a surrogate?:	Yes No
Explain if did you experienced any complication during any of your pregnancy:
Have you ever had a heterotopic or ectopic pregnancy?:	Yes No
Did you have the fallopian tube removed?:	Yes No
Are you current using any form of birth control?:	Yes No
If you are using IUD, would you be willing to have it removed prior the medical screening?:	Yes No
Do you have any reproductive condition with which you have been diagnosed?. List:
Any STDs that you have been diagnosed?:
Any STDs that your partner have been diagnosed?:
Letter to the intended parents:
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I accept terms and conditions:		*
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