To qualify as a surrogate you need to be between the ages of 21-40 (depending on health), have had prior children with no complications during pregnancy or birth, have regular periods, have no history of any genetically or sexually transmitted diseases, have no history of any serious or ongoing medical conditions, have never had a positive AIDS or HIV test, have reliable transportation, be a non-smoker, have never taken recreational drugs, be average weight for your height, and be committed to being a surrogate, which includes being available to attend medical office appointments during the treatment cycle and pregnancy.

Thank you for supplying information that may be sensitive. All information is strictly confidential.
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Which program are you applying for
First Name:
Middle Name
Last Name:
Maiden Name:
Address:
City:
Country or State:
Zip Code:
Phone:
Email:
Birth Date: //
Age:
Height: feet inches
Weight (EX: 120):
Ethnic Background:
Marital Status:
Smoker?
Have Health Insurance?
Insurance Company:
Have you ever been a surrogate before? Yes
How did you hear about us?
Comments / Questions:
 
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: Surrogate Overview
: Surrogate Fee Schedule
: Frequently Asked Questions