CNN's Egg Donor T-Shirt: For Serious Egg Donation Fans! - Northeast Assisted Fertility Group

Name *

First

Middle

Last

Address 1 *

Address 2

City *

State *

Zip *

Email *

Home Phone *

Cell Phone

Work Phone

What number is best to reach you at?

Home
Cell
Work

At which numbers may we leave a message for you?

Home
Cell
Work

Date of Birth *

Occupation

Marital Status

Spouse/Partner's name (if any)

Length of relationship

Spouse/Partner's occupation

Spouse/Partner's date of birth

If you are currently employed, please indicate start date of current job and provide a brief history of your past employment

If you are currently unemployed, how are you financially supported?

Do you have health insurance?

Yes
No

Health insurance is not required to be a surrogate

Please tell us how you heard of our program, and why you are interested in being a surrogate.

Have you informed your spouse, children, other family members, etc. of your interest in becoming a surrogate? If so, are they supportive?

Do you follow any particular religion?

Yes
No

Height *

Current Weight *

Have you ever been pregnant? *

Yes
No

Are your children currently living with you?

Yes
No

Are you currently taking any medications or do you have any illnesses or conditions?

Yes
No

Do you have regular menstrual periods?

Yes
No

Are you currently using birth control?

Yes
No

Have you had any sexually transmitted diseases?

Yes
No

Excluding childbirth, please list all hospitalizations and surgeries, including cosmetic surgeries:

Do you smoke?

Yes
No

Do you drink alcoholic beverages?

Yes
No

Do you take any recreational drugs?

Yes
No

How many sexual partners have you had in the past six months?

Have you been a surrogate or egg donor before?

Yes
No

Please describe, to the best of your ability, your ethnic background:

Have you ever been arrested or convicted of a crime?

Yes
No

Please describe the level of your education and degree dates:

Do you plan on having any more children of your own?

Yes
No

Would you be willing to travel for medical procedures related to your surrogacy?

Yes
No

Mother

Please let us know if there is any history of cancer, diabetes, mental illness, birth defects, heart disease, or any other conditions in your family.

Is your mother living?

Yes
No
Don't know

Father

Is your father living?

Yes
No
Don't know

Children

Siblings

Do you have or have you had any siblings?

Yes
No

Would you be willing to serve as a surrogate for a family of a different race, religion, or ethnic background from your own?

Yes
No

Would you be willing to serve as a surrogate for an unmarried couple as well as a married couple? Single parent or same sex parents?

Yes
No

Please specify any preference you may have:

Please read and agree to the following. *

I verify that the information on this application is complete and accurate. I understand that any false statement made by me may be viewed as perjury and in violation of the penal laws of my state and may subject me to criminal and/or civil penalties.

CNN’s Egg Donor T-Shirt: For Serious Egg Donation Fans!

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