Surrogate Application

Surrogate Application Form

The first step of becoming a Gestational Surrogate is completing the short introductory questionnaire below. It’s easy and takes about 5 minutes.

Personal Information

First Name *

Last Name *

Phone Number *

Email *

Street Address *

City *

State *

Zipcode *

Date of Birth *

Height *

Current Weight (lbs) *

Other Information

Number of Children*

Current age(s) of child(ren)*

Length of time carried in weeks for each pregnancy*

Number of C-sections, please state with which child?*

Please list any complications with any of your pregnancies (high blood pressure, preeclampsia, placenta previa, diabetes, etc. ) List N/A if no complications*

Are you currently taking any medications?*

Are you vaccinated against Covid-19?*

Have you had any tattoos or piercings in the last year?*

Single, Married, Dating*

Are you willing to travel out of state for an initial medical evaluation and then embryo transfer? (Travel costs will be covered by your intended parents.)*

Have you ever been a surrogate before?*

Are you open to selective reduction (in the case of triplets or more) and termination for chromosomal abnormalities?*

How did you find us?*

Ready to Begin Your Surrogate Journey?

If you’re ready to embark on the surrogate journey and make a meaningful difference in someone’s life, we invite you to schedule an initial consultation with our surrogacy specialists at Blossom Fertility. Our team is dedicated to ensuring a positive, rewarding, and fulfilling experience for surrogates, intended parents, and the precious new lives brought into the world.

Surrogate Application