Apply to be a Surrogate at Santa Monica Fertility Clinic in California

Please review this application before you begin in order to ensure that you have plenty of time to complete and submit the form to us. You will not be able to submit the form until all required fields are completed. Required fields are denoted by labels with a green asterisk.

If you are a human and are seeing this field, please leave it blank.

Section 1 of 6: Personal Information About 4 Minutes

Name*

First *

Last *

Phone Number *

Email *

Address

Line 1

Line 2

City

Zip Code

Country

How did you hear about us?

Date of last menstrual period?

Birthdate (mm/dd/yyyy)

Height (feet)

Weight (pounds)

Eye Color

Hair Color

Section 2 of 6: Requirements & Consent About 3 Minutes

Basic Requirements

I am a female non-smoker age 21-35

I have given birth and raised at least one child

Please note that you have to have given birth and raised at least 1 child in order to qualify.

Were your pregnancies complicated?

Does anyone living in your home, including yourself, smoke, abuse alcohol, or use recreational drugs?

I am comfortable taking medication to prepare my uterus for implantation and to help maintain the pregnancy and that medications may be in the form of a pill, vaginal suppository, a patch, or injection

Have you received any psychiatric care in the last ten years?

I am a citizen of the United States

I reside in the state of California

I have a reliable car with insurance

Are you receiving any federal or state financial assistance?

Do you have any ongoing legal disputes?

Consent

I agree to meet with a licensed mental health professional for a psychological exam

I am willing for a staff member to conduct a home visit

I understand a background check for myself and my husband/partner will be performed

I will allow a full medical examination which will include a vaginal ultrasound, pelvic examination, disease testing, and drug testing

I understand that my BMI must be 18 to 29 *

Section 3 of 6: Lifestyle About 3 Minutes

Your Occupation

Partner's Occupation

List prescription or other drugs you take

Alcohol consumption (frequency/amount)

If yes to weight change, please explain

If yes to another country, where, when, and for how long

If yes to mental illness treatment, please explain

If yes to arrest, please explain

Section 4 of 6: Reproductive History About 8 Minutes

For each pregnancy, please indicate the following:

Year of pregnancy

Number of months to conceive

Date of delivery

Number of weeks from conception to delivery

Birth weight (pounds and ounces)

Indicate any other details or complications

Name of obstetrician and hospital delivered

You may separate each item with a comma (e.g., "pregnant in 1998, 2 months to conceive, delivered 11/14/1998,...").

Pregnancy #1 details

Pregnancy #2 details

Pregnancy #3 details

Pregnancy #4 details

If yes to previously being a surrogate, please give details

If yes to other surrogate applications, when did you apply and what is your current status?

If yes to breastfeeding, how often and when will you stop?

If yes to placing a child for adoption, please explain

Menstruation

Are your menstrual periods regular?

Occasional bleeding after intercourse

Occasional bleeding between normal periods

My period usually lasts 4-6 days

What form of birth control are you using?

Age when you got your first period

Date of last pap smear

Please indicate the results of your last pap smear and provide details if abnormal or ever abnormal in the past.

Last pap smear details

Section 5 of 6: Your Children About 4 Minutes

Please provide the age, sex, and history of any health problems for each child (e.g., "Child #1: 13, male, asthma"):

Description of children

If yes to fertility treatments, please explain

If yes to C-sections, how many and what were the reasons

Section 6 of 6: Personal Preferences About 3 Minutes

Intended parents preference

Anyone

Domestic intended parents

International intended parents

Heterosexual intended parents

Same sex intended parents

Single intended parent (heterosexual)

Single intended parent (gay/lesbian)

Fetal Diagnostic Testing & Intended Parent Directives

With any pregnancy, there exists the possibility of a serious medical issue with the fetus or the possibility of Down Syndrome/chromosomal defect/anomaly or severe physical/mental abnormality. Intended parents may request the performance of a diagnostic test on the fetus such as a Chronic Villius Sampling (CVS) or an Amniocentesis in order to rule out any such serious condition. Should a serious condition be detected, the intended parents may request that such an at-issue pregnancy be terminated. It is important that we understand and respect your beliefs and perspective in regard to diagnostic testing of the fetus and possible termination of the pregnancy should a serious condition be detected.

Apply for Surrogacy at Santa Monica Fertility