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Gestational Carrier (Surrogate) Initial Intake Form

1Personal Info

Your comfort and privacy matters to us. These questions are important for finding the best match and ensuring your well-being throughout the process.

First Name

Last Name

Country

State

City

Phone Number

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Today Clear

What is your height?

What is your current weight?

lbs

Are you a citizen or permanent resident of the US?

Are you on any form of government assistance? (i.e. medicaid, food stamps, housing subsidies, etc)

What type of assistance are you using?

Do you have reliable transportation?

Have you carried at least one pregnancy successfully to term (36 gestational weeks, or more)?

How many c-sections have you had?

How many abortions have you had?

How many miscarriages have you had?

Have you ever been diagnosed with any of the following? Check all that apply.

Bipolar

Depression

Postpartum Depression

Anxiety

Schizophrenia

None

Have you ever been diagnosed with any of the following? Check all that apply.

Hypertension (high blood pressure)

Preeclampsia

Gestational Diabetes (controlled with medication)

Gestational Diabetes (controlled with diet)

Seizure Disorder

Auto-Immune Disease

Von Willebrand

None

Have you ever been diagnosed with any of the following? Check all that apply.

Endometriosis

Ovarian Cysts

Pelvic Inflammatory Disease (PID)

None

Please provide details.

Are you currently on anxiety or depression medication?

Have you ever been charged with a misdemeanor or felony?

Please list charge(s) and date(s)

Has your spouse/partner ever been charged with a misdemeanor or felony?

Please list charge(s) and date(s)

How did you hear about Flying Stork Surrogacy?

Please list the person's name

Other