Gestational Carriers
Application

Application Gestational Carrier Candidate

**NOTE: This is just a preliminary screener application. You will be provided with a full application upon receipt of this form**

Personal Information:





Educational Information:


Are you employed?*
YesNo
If you have answered yes, what is your occupation?



Relationship Status:



Is he/she employed?
YesNo
If you have answered yes, what is his/her occupation?



Are you married?
YesNo
If yes, when was your wedding date?

If No, Are you Engaged?
YesNo
If not married or engaged, are you in a relationship?
YesNo

Children/Pregnancy History

For each of these children, please provide the following info (Name, DOB, Sex, Birth Weight):

Were any of your children delivered via C-section?
YesNo
Were all of your children born healthy?
YesNo

If you have answered no, please explain:

Do you enjoy being pregnant?
YesNo
Do you intend to add more children to your own family?
YesNo
Have you ever had any abortions, miscarriages or stillbirths?
YesNo

If you have answered yes, please describe the timing and circumstances of each:

Were any of your children born prematurely or were there any complications with delivery?
YesNo
If the answer is yes, please describe the circumstances of each birth:

Medical
Are you currently on birth control?
YesNo
If so, what type?

Do you currently take any other prescription medications?
YesNo
If you have answered yes, please list the name, the dosage, the purpose of each medication, and whether or not you were on the medication during previous pregnancy(ies)

Have you ever been diagnosed with any of the following (please check all that apply):
Blood-clotting conditionDepressionGestational DiabetesHPVHerpesHepatitis (any form)HyperthyroidismPre-eclampsiaSTDsOther

If you have checked any of the above, please explain:

Do you currently Smoke?
YesNo
Do you currently use illegal drugs?
YesNo
Do you currently Drink Alcohol?
YesNo

If yes, how many drinks (on average) per Day:

If yes, how many drinks (on average) per Week:

If yes, how many drinks (on average) per Month:



Date of last OB visit:

Do you have health insurance?
YesNo
If yes, name of your insurance company

How did you hear about us?

Is there anything else you would like to add?