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Surrogate Mother Application
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Date
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Name
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Are you a permanent resident and currently living in the U.S.A.?
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Do you reside in one of the following states: AZ, IN, LA, MI, NE, NY, OK, WA?
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Are you between 21 and 43 years of age?
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Have you given birth to a child and are raising / or raised that child?
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Did you experience any complications during your pregnancy?
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Do you have personal medical insurance?
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Are you or anyone in your household currently receiving any form of government assistance (other than food stamps)?
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Do you currently smoke?
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Is your BMI currently 31 or higher?
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Have had 6 or more vaginal births?
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Have you had 3 or more c-sections?
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Have you been diagnosed with Post Partum Depression?
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Have you previously been diagnosed with Gestational Diabetes?
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Please share any information about yourself
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Home
Intended Parents
The Journey
>
Medical Procedures
Choosing An Agency
Costs
Surrogacy Laws
Gay Parenting
FAQ
Surrogate Mothers
Becoming a Surrogate
>
Surrogacy Requirements
Pre-Screening Process
The Surrogacy Process
>
Medical Procedures
Choosing an Agency
Surrogacy Laws
Surrogate Compensation
FAQ
Agency
Contact
Resources
In the News
Blog
Videos
Testimonials
Literature
Become a Surrogate Mother
