ELEVATE
Egg Donor Agency

Gestational Carrier Application

Elevate Surrogacy Logo.jpeg

Thank you for visiting our gestational carrier (surrogate) application page! This application should not take more than 5 minutes to complete. Once the application is submitted, our team will carefully review it and follow up with the contact information you provide. If you have any questions regarding this application, please feel free to contact us at the number or email address found at the bottom of this page.

Name *
Name
Month/Date/Year
Apt/Suite/Unit
Are you a United States Citizen or Permanent Resident? *
Are you Under 45? *
Are you currently married? *
Have you previously been a surrogate? *
Do you have biological children? *
Have you ever had infertility? *
Have you had any uterine anomalies, such as a septum, fibroids, or polyps? *
Have you suffered from a mental health disorder, such as depression? *
Have you had more than 3 cesarean births? *
Have you had more than 2 miscarriages? *
Have you ever had or currently have any heart disease? *
Have you ever had or currently have any type of diabetes? *
Have you ever had or currently have hypertension? *
Have you ever had or currently have any type of hepatitis? *
Do you have HIV? *
Do you smoke? *
Have you ever suffered or currently suffer from alcoholism? *
Have you ever suffered or currently suffer from drug addiction? *
Did you have hypertension during pregnancy? *
Did you have preeclampsia or eclampsia during pregnancy? *
Did you have Intrauterine growth retardation? *
Did you ever deliver preterm - before 37 weeks? *
Did you ever have placenta previa? *
Did you ever have placental abruption? *
Did you ever bleed during pregnancy? *
Did you ever have blood clots in pregnancy? *
Did you ever have diabetes in pregnancy? *
Did you ever have postpartum depression? *
Do you suffer from hypothyroidism? *
Do you have asthma? *
Do you have herpes? *
Have you ever been diagnosed with Syphilis? *
Have you ever been diagnosed with Gonorrhea? *
Have you ever been diagnosed with Chlamydia? *
Have you ever been diagnosed with Herpes? *
Have you ever been diagnosed with HIV? *
Have you ever had Hepatitis A, B or C? *
Have you ever been immunized for Hepatitis B? *
In the past six months, have you traveled to any of the countries affected by the Zika Virus as reported by the Center of Disease Control & Prevention (CDC)? *
https://wwwnc.cdc.gov/travel/page/zika-information
In the past six months, have you had sex with a male who has been diagnosed with the Zika virus or has traveled to one of the countries affected by the Zika virus? *
Has your partner ever been prescribed anti-depressants, anti-anxiety, or psychiatric medications? *
(Instagram, Facebook, Twitter)
Have you ever been arrested? *
Level of Education *
Are you currently employed? *
Are you currently receiving welfare, using Medicaid, or supplemental security income (SSI)? *
Do you currently have health insurance? *
Would you be okay carrying for a LGBTQ person or couple? *
Where did you hear about Elevate? *