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Preimplantation Genetic Diagnosis
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Blog
Get a Free Quote
Clinics Area
Treatments
IVF
ICSI IVF
Egg Donation IVF
Sperm Donations IVF
Embryo Donations IVF
Genetic Testing IVF
Surrogacy
Commercial Surrogacy
Altruistic Surrogacy
IUI
Freezing
Egg Freezing
Sperm Freezing
Embryo Freezing
Donate
Become a surrogate
Become an egg donor
About Us
FAQ
Treatment Solutions
Choosing In-Vitro Treatment
Intrauterine Insemination
Surrogacy Q & A
Two–Mommies Programs
Two–Daddies Programs
Preimplantation Genetic Screening
Preimplantation Genetic Diagnosis
PGS & PGD
Blog
Get a Free Quote
Clinics Area
Become a surrogate mother.
Fill the form to apply for surrogate mothers program
Become a surrogate mother
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First name
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Last name
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Enter Email
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Enter Phone
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What is Your preferred method of communication:
Phone call
Email
Whatsapp text
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Location of residence
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Zip code
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Please choose your Date of Birth
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Have You given birth before?
No
Yes
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Ethnicity
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What makes you want to become surrogate?
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Please list past pregnancies
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Delivery type
Vaginal
C Section
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Sex
Male
Female
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Weight
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Weeks of Gestation
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Are You currently pregnant?
No
Yes
We are unable to work with women who currently pregnant, but we will happy to work with you in future. Once your baby will be successfully delivered and you fullfill your breastfeeding obligations, meanhile we will help you explore more about surrogacy!
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Have You been a surrogate before?
Yes and I carried baby(ies) to term
Yes but I did not carried baby(ies) to term
Yes and I matched with intended parents but never become pregnant
No I have never been surrogate before
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Have You Ever Experienced a Still Birth(s)?
No
Yes
We are currently can't work with women who experienced still births as per IVF clinics guidelines
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Height
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Weight
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Would you agree to terminate a pregnancy for medical reasons if requested by the intended parents?
Yes
No
A medical reason could include a chromosomal abnormality or a condition that would impact the child's quality of life.
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Please list any prescribed medications you are currently taking. If you are not taking any medications, please write "none".
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Are you vaccinated against COVID-19?
Yes
Not yet but I am willing to discuss getting the COVID-19 vaccine for a surrogacy
No I am not willing to get the COVID-19 vaccine for a surrogacy
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Check off any of the following conditions with which you have been diagnosed
Tuberculosis
Rubella (German Measles)
Serious Birth Defects
Diabetes (Please elaborate if diet controlled or insulin controlled)
Liver or Renal Disease
Heart Attack Before 50
Severe Bleeding Tendency
Cystic Fibrosis
Neurofibromatosis
Progressive Kidney Disease
Congenital Heart Defects
Hypertension
Seizure Disorder
Bipolar Disorder
Cataracts (before age 40)
Rheumatoid Arthritis
Organ removal
Cancer
Other
Auto-immune disorders (such as fibromyalgia multiple sclerosis Crohn's disease rheumatoid arthritis)
Blood Clotting Disorder
None of the above
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Are you receiving any of the following additional forms of government financial assistance?
Food Stamps
Medicaid
Cash Assistance/Welfare
Financial Aid
WIC
SSI
Public Housing/Section 8
Government Subsidized Childcare
Student Loans/Grants
Other (please specify)
None of the Above
We are unable to work with women who receive certain forms of government assistance due to requirement of IVF clinics working with us
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Have you received a high school diploma or GED equivalent?
yes
no
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What is your occupation?
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What is your marital status?
Married
Engaged
Relationship (co-habitating)
Relationship (living separately)
Single
Divorced (finalized)
Divorced (in progress)
Legally Separated
Separated (Non-legally)
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Will you have a partner or spouse on this journey with you?
No
Yes
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What is your combined household annual income?
$
We fully acknowledge that personal income varies from country to country, so we will make sure to take this factor in consideration when communicating with IVF clinics. A surrogate's financial stability is an important aspect to her journey. We want to make sure that she is able to support her family and care for all her needs. Our hope is to better understand your personal situation as you complete a full screening process.
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Have you ever been convicted of a crime?
No
Yes
We acknowledge there are many categories to which being convicted of crime falls under. Our hope is to better understand your circumstances as we begin journey with you. It will not disqualify immediately as we look into any of ours's patient case with very flexible approach.
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Do you or your partner currently have any outstanding legal obligations (bankruptcy, divorce proceedings, lawsuits, misdemeanor, and/or criminal offenses)?
No
Yes
There are many laws surrounding a surrogacy which we are committed to following for both surrogate and intended parents. In some situations if a surrogate is engaged in current legal matters such as those mentioned above, our ability to provide a smooth journey from a legal perspective could be compromised. By learning about your current legal obligations, we will be better equipped to set your journey up to success.
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How would you describe your readiness for surrogacy right now?
I'm ready to start and match NOW!
I'm interested in matching in 3 to 6 months
I'm interested in matching in 6 or more months
I'm not sure I'm looking for more information
I'm early in my research
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Do you and / or your partner have any past, current, or ongoing open cases with Child Protective Services?
No
Yes
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Would you consider moving to another country for procedure?
Yes
No
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I understand that all information I enter here will be stored on the website, but will not be publicly visible nor searchable, except for by the Administrators of the website. I understand that I may be contacted by the Administrator of the website.
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Email Address
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Password
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Enter Email
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Confirm Email
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I understand that information I choose to enter into this website, including my name, phone number, and location may be stored, publicly available, and searchable on this website. I understand that I have the ability to change or remove this information at any time.
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Clinic Login
Register New Clinic Account
Clinic Login
*
Email Address
*
Password
Forgot Password? Click to Reset Password
Are you a patient?
Get a FREE Quote from Clinics
Are You a Fertility Clinic?
List Your Company Now
You are creating a new CLINIC Account
If you are a patient please use this form:
>Patients<
Enter Email and Create Password
*
Enter Email
*
Confirm Email
*
Create Password
*
Confirm Password
*
I understand that information I choose to enter into this website, including my name, phone number, and location may be stored, publicly available, and searchable on this website. I understand that I have the ability to change or remove this information at any time.
The security check was not completed successfully.
