The Egg Donor Program - Online Application

The Surrogacy Program
Shelley B. Smith M.A., M.F.C.C.

Surrogate Application Form

The Surrogacy ProgramShelley B. Smith M.A., M.F.C.C.

Surrogate Application Form

The Surrogacy Program
Shelley B. Smith M.A., M.F.C.C.

4184 Colfax Ave.
Studio City, CA 91604

Fax: (818) 506-9763 Phone: (818) 506-9300

Surrogate Information

The information contained on this page will be kept confidential. Information in "Surrogate Application Form" will be shown with discretion to prospective recipients.

First Name:
Last Name:
Email:
Street Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Preferred Means of Contact:
Birth Date:
In case of emergency notify:
Relationship:
Phone:
Who referred you?
Employer:
Primary Health Ins. Co.:
Do you own a car?	Yes No
Drivers Lic. State:
Drivers Lic. No.:
Drivers Lic. Exp.:
Spouse's D.L. State:
Spouse's D.L. No.:
Spouse's D.L. Exp.:
Do you have automobile Ins.?:	Yes No
Have you been a surrogate before?:	Yes No

FERTILITY HISTORY

Number of Children:

# male:
ages:
# female:
ages:

Number of Pregnancies:

Year:
Duration:	months
Year:
Duration:	months
Year:
Duration:	months
Year:
Duration:	months
Year:
Duration:	months

Number of Abortions:

Number of Miscarriages:

WORK HISTORY

(Please indicate if you are a homemaker.)

Occupation	Dates of Employment	Exposed to Chemicals or Gases?
		Yes No
		Yes No
		Yes No

Are you currently working? Yes No
Are you currently receiving state or federal aid (including but not limited to WIC, CalWORKS, Cash Aid, CalFresh food stamps)? Yes No
If you answered 'Yes' please specify what type of aid you are receiving in this space below.
What are your career goals?

ACADEMIC BACKGROUND

High School (No. of Years): College (No. of Years):
Major:
Degree:
Educational Goals:

HEALTH INFORMATION

Blood Type:
General Health Condition:
Do you have any medical problems?	Yes No
Please Explain:

PAST MEDICAL PROBLEMS

Condition	Date	Surgery / Treatment	Resolution


	LIFESTYLE Do you smoke? Yes No Number per day : Alcoholic Beverages : Yes No Number per week : Do you exercise? Yes No Types : How Often? Hobbies / Interests:

PERSONALITY

Please describe your personality and character :

Why do you want to be a surrogate?

What message would you like to pass on to the prospective parents?

What kind of support will you have from the following people in your life?

Your husband / boyfriend :

Your own parents :

Friends / co-workers :

What qualities would you consider most important in choosing a recipient couple?

How would you respond if the child wanted to meet you?

Would you like to have the couple in the delivery room?

Is there anything else you need from the program in order to do this?

Has your weight changed dramatically in the last five years? If so, why?

Please explain any birth / pregnancy complications : (premature, toxemia, gestational diabetes, placenta previa, bedrest ordered by doctor)

Did you need any medical help conceiving your children?

Did you take more than six months in conceiving your children?

If there was a serious problem with the pregnancy and the prospective parents wanted to consider abortion, would you be willing to abort? Yes No

Do you and your partner understand that, unless you have had a tubal ligation or unless your partner has had a vasectomy, you must agree to abstain from sexual activity while attempting to achieve a pregnancy for the couple? Yes No

I certify that this information is correct.

Full name :

Date :

Birth Weight

Months to Conceive

Complications