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Family Building
Intended Parents
Surrogates
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Login
- My Journey
- My Escrow Account

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Family Building
Intended Parents
Surrogates
Blog
Login
- My Journey
- My Escrow Account

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Surrogate Application Form

1CONTACT INFORMATION

2BACKGROUND INFORMATION

3Personal Characteristics

4Medical History

5Personal Characteristics

Surrogate Name*
Email*
Mailing address*
City, State ZIP*
Phone number*
Best Time to Contact*

Date of Birth*
MM slash DD slash YYYY
Have you ever been a surrogate?*
If so when?*
Present Employer
Present Occupation
Marital Status*
If married, how long have you been together?*
Spouse Name*
Spouse Birth Date*
MM slash DD slash YYYY
Spouse’s Employer*
Spouse’s Occupation*
Have you or your spouse ever?*
- Filed Bankruptcy
- Been turned down by an adoption agency
- Been past due on child support
- Been in a substance abuse program
- Have current legal cases or claims pending
- None of the above
Have you ever been convicted of a crime?*
- Yes
- No

Height*
Weight*
Is your bone structure*
What is the highest level of education that you have attained?*
What is your religion?*
Do you practice?*
What is your race? (Check All that Apply)*
- White
- Black
- Hispanic/Latino
- Asian
- Hawaiian/Pacific Islander
- American Indian/Alaska Native
What languages do you speak?*
What other languages do you speak?*
Insurance Information
Insurance Carrier*
Effective Date*
MM slash DD slash YYYY
Name of Primary Insurance Holder*
Does your insurance provide maternity care coverage?
- Yes
- No

How many successful pregnancies have you had?*
How many miscarriages have you had?*
Have you ever had an abortion?*
If so when?*
Have you ever had a stillbirth?*
If so when?*
Pregnancy #1
Child’s first name*
First
Child's Gender*
Date of Birth*
MM slash DD slash YYYY
Full term?*
Birth Weight*
Birth Delivery*
Weeks at Delivery*
Complications:*
Pregnancy #2
Child’s second name:*
First
Child's Gender*
Date of Birth*
MM slash DD slash YYYY
Full term?*
Birth Weight*
Birth Delivery*
Weeks at Delivery*
Complications:*
Pregnancy #3
Child’s third name:*
First
Child's Gender*
Date of Birth*
MM slash DD slash YYYY
Full term?*
Birth Weight*
Birth Delivery*
Weeks at Delivery*
Complications:*
Pregnancy #4
Child’s fourth name:*
First
Child's Gender*
Date of Birth*
MM slash DD slash YYYY
Full term?*
Birth Weight*
Birth Delivery*
Weeks at Delivery*
Complications:*
Pregnancy #5
Child's fifth name*
Child's Gender*
Date of Birth*
MM slash DD slash YYYY
Full term?*
Birth Weight*
Weeks at Delivery*
Complications:*
Pregnancy #6
Child's sixth name*
Child's Gender*
Date of Birth*
MM slash DD slash YYYY
Full term?*
Birth Weight*
Weeks at Delivery*
Complications:*
Pregnancy #7
Child's seventh name*
Child's Gender*
Date of Birth*
MM slash DD slash YYYY
Full term?*
Birth Weight*
Weeks at Delivery*
Complications:*
Pregnancy #8
Child's eighth name*
Child's Gender*
Date of Birth*
MM slash DD slash YYYY
Full term?*
Birth Weight*
Weeks at Delivery*
Complications:*
Pregnancy #9
Child's ninth name*
Child's Gender*
Date of Birth*
MM slash DD slash YYYY
Full term?*
Birth Weight*
Weeks at Delivery*
Complications:*
Did you need medical assistance in achieving a pregnancy?*
Did you take more than 6 months to conceive your child(ren)?*
What is your current method of birth control?*
Age of first menstruation?*
Are your menstrual cycles regular?*
Is there family history of fertility problems in your family?*
What is your daily activity level?*
What do you eat on a typical day?*
Do you smoke?*
Does anyone in your household smoke?*
Are you on any prescription medications?*
If yes, please indicate which ones and the reason:*
Do you take any non-prescription drugs?*
If yes, please indicate which ones and the reason:*
Have you been vaccinated against Hepatitis B?*
Have you been vaccinated against COVID-19?*
Do you drink alcohol?*
How often?*
Have you ever abused alcohol?*
Do you or have you ever used illegal drugs?*
Have you ever had to receive psychological counseling (including substance abuse counseling, marriage or family therapy)?*
If yes, please explain:*
Have you ever been under the care of a psychiatrist?*
If yes, please explain:*
Please list any significant illnesses you have had:*
Have you had or currently have any of the following conditions:*
- Bleeding or Clotting Disorders
- Cancer
- Diabetes
- High blood pressure
- Gestational diabetes
- Preeclampsia
- Hepatitis
- Seizure Disorder
- Liver Disease
- Kidney Failure
- Thyroid Disease
- None
Have you ever had surgery?*
If yes, please explain:*
Have you ever been hospitalized other than listed?*
Have you ever had major radiation or x-ray exposure?*
Have you ever had any jobs, hobbies, or activities that could have exposed you to chemicals, drugs, or gasses?*
When was your last physical exam?
Month*
Year*
OBGYN Address:*
When was your last pap smear?
Month*
Year*
Were the results normal?*
Have you or your partner had any sexually transmitted diseases?*
If yes, please specify:*
Have you ever donated blood or had a blood transfusion?*
Do you and your partner understand that unless you have had a tubal or your partner has had a vasectomy that you must abstain from sexual intercourse while attempting to achieve a pregnancy for a couple during the medicating stages?*
Are you willing to take health related tests at the expense of the prospective parent(s)?*
Are you comfortable taking medications by injection?*

Describe your personality:*
What kinds of hobbies or activities do you enjoy?*
Please describe your future goals (personal and career):*
How do you manage stress in your life (particularly to periods that you have been pregnant)?*
Surrogacy Information
Have you applied to any other programs to be a surrogate?*
If yes, which one?*
Are you willing to travel to another state for an embryo transfer procedure? (We only work with US clinics. All travel costs are fully covered by your Intended Parents).*
Are you willing to work with Intended Parents that live in another state?*
Are you willing to work with Intended Parents that live internationally?*
Briefly explain your personal reasons for wanting to be a surrogate:*
What qualities do you consider to be most important in choosing to work with prospective parents?*
What type of couple are you willing to help? ( Check all that apply )*
- Married
- Unmarried
- Single
- Gay
- Lesbian
- Doesn’t Matter
As a surrogate, would you have any concerns with the prospective parents participating in the birthing process?*
How do you feel being a gestational surrogate will affect your life? How might it prove difficult?*
How much contact would you like with the parents during pregnancy, delivery and after the child is born?*
During the surrogacy process, who can you expect to receive emotional support from? And how do they feel about your decision to become a surrogate?*
Is your husband/partner aware of his responsibilities in the medical process and how willing is he to cooperate (such as abstinence, testing)?*
What are your biggest concerns about becoming a gestational surrogate?*
Would you consent to prenatal testing for birth defects?*
Are you open to selective reduction in the event of high-order multiples?*
Are you open to termination in the case of a major medical issue or significant congenital malformation resulting in little or no life expectancy for the fetus?*
Are you open to termination in the event of a Down Syndrome diagnosis?*
Are you open to termination in the event of a chromosomal abnormality other than Down Syndrome?*
How many transfer attempts would you feel comfortable with in order to become pregnant?*
- 1
- 2
- 3
- 4+
Do you have objections to carrying multiples?*

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1050 Queen St. Suite #100 Honolulu, HI 96814
(808) 215-0290
information@hawaiisurrogacy.com

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