Continue your surrogate application with EDSI.

You are now ready for the full surrogate application. This is required before your consultation. The application gives our medical

and coordination team the information they need to continue your screening.

NEXT STEP: finish your surrogate application

Full Name *

What is your Email? *

What is your phone number? *

Date of birth *

Ethnicity *

What languages do you speak? *

Have you ever been a Surrogate? *

Yes

No

How many times have you been a surrogate?

How did you hear about us? *

Facebook

Instagram

TikTok

YouTube

Google search

ChatGPT or AI search

Doctor's office

Friend/Family

Referral from surrogate

Referral from intended parents

Attorney

Podcast

Blog or article

Advertisement

Other:

Have you ever had a blood transfusion? *

Yes

No

Do you currently use drugs? *

Yes

No

If you currently use drugs, what type and how often?

What kind of support system do you have during your surrogacy journey?

How many pregnancies have you had? *

0

1

2

3

4

5

6

Living *

0

1

2

3

4

5

6

Miscarriages *

0

1

2

3

4

5

6

Abortions *

0

1

2

3

4

5

6

Ectopic *

0

1

2

3

4

5

6

Child 1 Age Gender DOB *

Child 1 Vaginal or C Section *

Vaginal

C Section

Child 1 Weeks delivered weight Additional info *

Child 2 Age Gender DOB

Child 2 Vaginal or C Section

Vaginal

C Section

Child 2 Weeks delivered weight Additional info

Child 3 Age Gender DOB

Child 3 Vaginal or C Section

Vaginal

C Section

Child 3 Weeks delivered weight Additional info

Child 4 Age Gender DOB

Child 4 Vaginal or C Section

Vaginal

C Section

Child 4 Weeks delivered weight Additional info

Child 5 Age Gender DOB

Child 5 Vaginal or C Section

Vaginal

C Section

Child 5 Weeks delivered weight Additional info

Do you have regular monthly menstrual cycles? *

Yes

No

How many days does your period last? *

Do you have any history of STDs *

Yes

No

If yes, what type STD?

When was your last pap smear?

Do you have a history of any abnormal pap smears? *

Yes

No

Do you use birth control? *

Yes

No

What type of birth control are you using? *

IUD

Nexplanon/ Implanon

Birth Control Pill

Depo Shot

Nuva Ring

Condoms

Partner- Vasectomy

Tubal ligation

Abstinence

Are you currently breastfeeding? *

Yes

No

Ever diagnosed or prescribed medications for depression, anxiety, bipolar, or any other mood disorder? *

Yes

No

If yes, what is the diagnosis and the medication

Have you had your COVID vaccines? *

Yes

No

Are you open to having any necessary vaccines at the request of the IPs or the doctor? *

Yes

No

Are you on any medications?

Have you undergone any fertility treatments to get pregnant? *

Yes

No

Have you ever had any medical problems? Please explain.

Have you ever been hospitalized other than for deliveries? *

Yes

No

If you've been hospitalized, please explain

Have you had any type of surgery other than C-section? *

Yes

No

If you have had surgery, please explain

Have you ever lost custody of a child or had a child removed from your home? *

Yes

No

Have you ever been arrested? *

Yes

No

If you have been arrested, what year and what for?

Do you have a driver's license? *

Yes

No

Do you have a car? *

Yes

No

If no, form of transport

Are you employed? *

No

Full time

Part time

What kind of work do you do? *

Are you currently active in the military or reserves? *

Yes

No

Are you currently receiving the following? *

AFDC

Disability

SSI

Food Stamps

Cash Aid

None of the above

Other

Medical Insurance *

Yes

No

If yes, who is your medical Insurance through

Have you applied to any other medical facility, law firm, and/or agency as a surrogate mother? *

Yes

No

What is your relationship status? *

Married

Single

Divorced

Partner

Other

Partner's Name

Partner's Email

Live together?

Yes

No

Partner US Citizen

Yes

No

If your partner is not a US citizen, what is their citizenship status?

Has your partner ever been arrested?

Yes

No

If your partner has been arrested, what year and what for?

How long have you and your Spouse/Partner been together?

If Married, how many years have you been married?

Is your partner aware and supportive of you becoming a surrogate?

Yes

No

N/A

Would you terminate for Down's Syndrome at your IP's request?

Yes

No

Are you willing to reduce a triplet pregnancy to a twin pregnancy? *

Yes

No

If there is a serious medical problem with the fetus you are carrying and the IPs want to consider a termination, would you allow them to make a decision? *

Yes

No

Name of person who referred you to EDSI

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