Surrogate App

© 1996-2002 Surrogate Alternatives, Inc.. All Rights Reserved. Important Legal Information Privacy Rules and Regulations
1995 Moss Landing AvenueChula Vista, CA 91913 1.619.397.0757

First name:		Your age:
Blood Type:	Height:
Eye Color:		Weight:
Hair Color:		State:
Do you have any children:?	How Many:
Ethnic background:
What is you Marital Status:

Have you ever had an abortion or miscarriage?
What type of relationship do you and your husband or boyfriend have?
If there ends up being something medically wrong would you abort?
Do you have any objections to carrying multiples (more than one baby)?
Would you agree to an Amniocentesis procedure?
What was the date of your last pap smear? (year, results)
What do you do for a living?
What does your spouse/partner do for a living?
Will you with work a gay couple?

Must have given birth to at least one child and be raising that child
Must be between the ages of 21-40 (if the Surrogate is between the ages of 37-40 she must have delivered a child in the last 2 years, and be able to provide a physician's clearance)
Can not be receiving any government assistance
No serious medical problems during pregnancy or delivery
No pre-term deliveries before 36 weeks (unless in the event of multiples)
Must be able to provide Surrogate Alternatives with previous delivery records
Must be willing to undergo a psychological evaluation
No Abnormal pap within last 3 years
Must be willing to be Medically tested as well as the Surrogates husband/partner
No criminal history of any kind
Must have a stable residence and not be planning to move out of the county in which the Surrogate resides, from the time she submits her application until after the delivery of the child(ren)