Contact

First Name *

Last Name *

Phone *

Email *

Demographics

I am between the ages of 21 and 39; up to 42 for recent pregnancy or repeat gestational carrier. *

True

False

I reside in South Carolina (or within a 1-hour drive of the SC border). *

True

False

Demographics

I am a US citizen (or, if not, have a Permanent Resident Card) *

True

False

I speak and read English fluently. *

True

False

Lifestyle Habits

I do not smoke (this includes e-cigarettes or vape pens). *

True

False

I own a vehicle and have a valid driver’s license. *

True

False

Health

I am willing to gestate twins if I become pregnant with twins. *

True

False

I am not on any type of mental health prescription (e.g., antidepressants). *

True

False

Financial History

I do not receive any type of governmental assistance (including Medicaid). *

True

False

My children do not receive any type of governmental assistance (this includes social security benefits or Medicaid). *

True

False

Pregnancy History

I have given birth to at least one child whom I am raising. *

True

False

My pregnancies have been healthy with no complications (e.g., no gestational diabetes). *

True

False

I am currently pregnant. *

True

False

Unsure

Staying in Touch

How would you like to hear from our surrogacy case manager regarding your questionnaire?

Text

Phone Call

How did you find out about our office?

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