Full application – GTS

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First Name

Last Name

Email

Phone

Date Of Birth *

Are you currently a citizen or permanent resident of the United States?

Country

State

City

Do you have any plans of moving to another state in the next 18 months?

If yes, which state? Please specify

What is the best time of day to contact you by phone?

What is your highest level of education?

Height (Feet)

Height (Inches)

Weight? (Pounds)

BMI

Have you been a Surrogate before?

Do you have reliable transportation?

Primary Ethnic Background

If American Indian, are you a registered member of a Native American Tribe?

Are you receiving Section 8 rental housing assistance?

Are you receiving any financial assistance from the government including welfare or Medicaid?

Have you received the COVID vaccine? *

How would you rate yourself as an alcohol consumer, with 0 being a non-drinker and 10 being a frequent daily drinker?

(0/10)

How would you rate yourself as a smoker, with 0 being a non-smoker and 10 being a frequent daily smoker?

(0/10)

What is your relationship status?

Do you and your partner agree to a background check as required for surrogacy?

Emergency Contact 1: Name

Emergency Contact 1: Relationship

Emergency Contact 1: Telephone number

Emergency Contact 2: Name

Emergency Contact 2: Relationship

Emergency Contact 2: Telephone number

Have you or your partner/spouse ever been charged with a felony?

Explain:

Have you or your partner/spouse ever been charged with a misdemeanor?

Explain:

Have you ever been diagnosed with any of the following:

Have you ever been diagnosed with any of the following:

Have you ever been diagnosed with any of the following:

Have you had any abortions?

How many abortions have you had?

Please list the year for each abortion

Have you had any miscarriages?

How many miscarriages have you had?

Please list the year for each miscarriage.

How many pregnancies have you carried through to delivery?

How many c-sections have you had?

Have you ever had preterm labor (less than 36 weeks) or received Makena® (hydroxyprogesterone caproate injection) injections?

1st Child Delivery Type

1st Child Weeks of Gestation

1st Child Date of Birth

1st Have you had any complications during the weeks of pregancy?

2nd Child Delivery Type

2nd Child Weeks of Gestation

2nd Child Date of Birth

2nd Have you had any complications during the weeks of pregancy?

3rd Child Delivery Type

3rd Child Weeks of Gestation

3rd Child Date of Birth

3rd Have you had any complications during the weeks of pregancy?

4th Child Delivery Type

4th Child Weeks of Gestation

4th Child Date of Birth

4th Have you had any complications during the weeks of pregancy?

5th Child Delivery Type

5th Child Weeks of Gestation

5th Child Date of Birth

5th Have you had any complications during the weeks of pregancy?

How did you hear about us?

If you heard about us from an event, please put the name of the event

If someone or a clinic referred you, please put the name of the clinic or person