**Surrogate Qualification Questions

To make sure that you are potentially a suitable surrogate, we would like to ask a few qualification questions. Please answer the following questions honestly.

Are you between the age of 21 and 40 years old?

We require applicants to have a driver license and reliable transportation. Do you have both of those?

If no, please explain

Have you ever been diagnosed with Diabetes (not including gestational diabetes)?

If yes, please explain when you were diagnosed, what type, and are you on medication and/or insulin

Have you ever been diagnosed with Hyper-tension (high blood pressure)?

If yes, please explain when you were diagnosed, do you still have it, and are you on medication for it

Have you ever been diagnosed with Pre-eclampsia?

If yes, please explain what year you were diagnosed, and at what week in the pregnancy, as well as how severe and treatment.

Are you currently taking or have taken in the last 6 months any anti-depressant or anxiety medications?

If yes, please explain. What medication it was, why you were taking it, when did you start taking it, and the last time you took it.

Have you ever been admitted into a psychiatric facility?

If yes, please explain. When you were admitted, why you were admitted, and how long did you stay.

Have you ever been diagnosed with Schizophrenia, Bipolar Disorder, or Post Traumatic Stress Disorder?

If yes, please explain which diagnosis, when you were diagnosed, are you under the care of a doctor, and are you on any medications for it.

Have you or your partner tested positive for a sexually transmitted disease in the past 2 years?

If yes, please explain. Please specify if it was you or your partner, what the diagnoses was, when were you diagnosed, and what was the treatment plan.

Have you ever been diagnosed with incompetent cervix or cervical insufficiency?

Have you ever been incarcerated?

If yes, please explain. When you were incarcerated, what was the charge/reason, how long were you incarcerated, and what was the outcome.

Have you or your partner ever been convicted of a felony?

If yes, please explain. Who has the felony, what year was the felony charge, what was the charge for, and what was the outcome.

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

If yes, please explain.

Have you ever been in a substance abuse program?

If yes, please explain. What program were you in, for what substance, and long did you attend the program.

We require all applicants to take a drug test. Would this be a problem?

Have you smoked cigarettes and/or used tobacco in the past 12 months?

If yes, please explain. When was the last time you smoked, how often do you smoke, are you willing to take nicotine testing?

Have you given birth before?

Have you or are you raising a child?

If no, please explain:

Have you had more than 3 c-sections?

If yes, please explain how many C-Sections you have had.

Are you on any type of birth control right now(pill, IUD, etc.)?

What type of birth control and for how long?

Are you currently receiving any form of government assistance (food stamps, AFDC, state insurance, WIC, housing?

If yes, please explain. List all Assistance Programs you are receiving at this time.

If you are receiving Government assistance there is a very strong possibility that you will lose all benefits when entering into a contract between you and an Intended Parent. Knowing this, do you still want to move forward with the surrogacy process?

Yes

No

If your application is approved, are you willing to have full medical records released to Prime Genetics?

Do you have health insurance?

If yes, which company is your health insurance with?

If your application is approved, are both you and your partner (if applicable) willing to have a full background check conducted and released to Prime Genetics?

If no, please note that we will not be able to move forward with the surrogacy process without background consent forms signed.

Are you willing to make lifestyle changes such as abstaining from alcohol, caffeine, marijuana, and other substances at the request of the intended parents?

If no, please explain what you are not willing to change or abstain from during a surrogacy pregnancy.

Have you had the COVID vaccination?

Are you willing to get the COVID vaccination if the intended parents ask that of you?

Please explain why you are unsure.

If there is anything else you would like us to know, please explain to the best of your ability. Thank you

We will verify your responses to these questions before accepting you into our program.