Questionnaire

Surrogacy Plus
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Prescreening Questionnaire

Estimated completion time:
3-5 minutes

To be considered as a surrogate you must already have at least 1 child.

You must maintain a safe healthy weight: (here is a list of the max weight per height to be considered as a surrogate):

height weight height weight

5' 164 lbs 5'6" 199 lbs

5'1" 170 lbs 5'7" 205 lbs

5'2" 175 lbs 5'8" 211 lbs

5'3" 181 lbs 5'9" 218 lbs

5'4" 187 lbs 5'10" 224 lbs

5'5" 193 lbs 5'11" 230 lbs

Please note: If your current weight above the maximum for your height, please come back to apply after reaching the target weight for your height.

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1. What is your First Name? *

2. What is your Last Name? *

3. What is your Date of Birth? *

4. What is your primary phone number? *

5. Do we have your permission to text at this number? *

6. What state do you live in? *

7. Are you a US citizen or a permanent resident? *

If no, what is your country of residence?

8. How many pregnancies have you completed successfully? *

9. How many of your deliveries were C-section deliveries? *

10. Are you receiving any federal or state financial assistance? *

11. What is your height? *

12. What is your weight? *

13. What is your relationship status? *

14. How did you hear about us? *

15. I consent to the storage and processing of personal data submitted through this form. *

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