Register a Surrogate – Egg Donor Texas

Gestational Surrogacy Questionnaire

To become a Gestational Carrier, we need to learn some information about your personal and medical history. Your responses to these questions will help us assess whether your health and medical history are compatible with the gestational surrogacy process. This effort will also help us match you with appropriate intended parent(s). Please provide complete and accurate information to these questions. Please do not leave any field blank. If information is unknown, enter "unknown.” If not applicable, please enter "N/A."

Step 1 of 3

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- I am between the age of 21 and 39
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- My Body Mass Index (BMI) is between 18-32
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- I do not have a criminal history
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- I have carried and given birth to a child at least once
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- I am not currently receiving government assistance
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- I do not smoke or use illicit drugs
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- I agree to psychological testing (spouse/partner as well if applicable
SECTION 1: Personal Information
Full Name:*
First Middle Last
Maiden Name:
Nickname:
Email:*
Phone:*
Date of Birth:*
MM slash DD slash YYYY
Height:*
Weight:*
Body Frame (Sm/Med/Lg):
Blood type and Rh factor if known:
Body Mass Index (BMI) if known:

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Give the Gift of Life

Become a Surrogate

Gestational Surrogacy Questionnaire

Step 1 of 3

SECTION 1: Personal Information