916-303-0094
Surrogate Form


Thank you for your interest in working with GS Moms on your surrogacy journey! Please fill out the screening form below and we will get back to you as quickly as we can.

What is your name?

What is your nickname?

What is the best way to contact you?
emailPhoneText

Do you live in the United States?
YesNo

Do you live in New York, Michigan, or Nebraska
YesNo

Do you speak and understand English?
YesNo

Are you between the ages of 20 and 40 years old?
YesNo

Have you used any tobacco products in the last year?
YesNo

Do you have any history of illegal drug use or alcohol abuse?
YesNo

Have you or your partner ever been convicted of a crime?
YesNo

Have you used antidepressants in the last year?
YesNo

Have you given birth to at least one child in the last 10 years?
YesNo

Have you had two or more miscarriages?
YesNo

Do you have at least partial custody of and live with at least one of your children?
YesNo

Will you be dependent upon your surrogacy income as your primary means of support?
YesNo

Are you currently accepting Welfare payments?
YesNo

As part of the surrogacy process, are you willing to take injectable medications and oral birth control?
YesNo

Would you be willing to terminate a pregnancy if medically advised to do so?
YesNo

How old are you?

Date of birth

Ethnicity
WhiteHispanicBlack or African AmericanNative Hawaiian or Other Pacific IslanderIndianAsianNative American or Alaska NativeOther

Height

Weight

Email Address*

Your Cell Phone Number

Your Home Phone Number

Your home address

Do you have health insurance?
YesNo

If you have health insurance who is your health insurance provider?

How did you hear about us?

If you were referred by a friend please let us know who to thank!

Do you have reliable transportation?
YesNo

Do you have or have access to a computer?
YesNo

When was your weight last obtained?

How often do you check your email?
ObsessivelyDailyWeeklyNot OftenHardly Ever

When would you like to start your Surrogacy journey?
ImmediatelyWithin a MonthWithin 3 MonthsJust looking for Information

Have you been a surrogate before?
YesNo

When is the best time for our team members to contact you?

Does your household own a car?
NoYes

If not, what is your means of transportation?

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Success stories of growing families

At Gestational Surrogate Moms we pride ourselves on the perfect match of donor and surrogate tointended families. Here are some stories of success:

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