Gestational Carrier Application

Apply to Change a Life.

Thank you for visiting our gestational carrier (surrogate) application page! This application should not take more than 2 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 us the contact form or the phone number found at the bottom of this page.

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Street Address

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Street Address 2

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City

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State

Height(Required)

Current Weight(Required)

Are you a United States Citizen or Permanent Resident?(Required)

US Citizen

International

Permanent Resident

What form of transportation do you use?(Required)

Drive your own car? Take public transit? Other?

Do you have a valid Driver's License?(Required)

Have you previously been a surrogate?(Required)

Yes

How many children have you given birth to?(Required)

Have you ever given birth to multiples ?(Required)

(twins, triplets, etc)

How Many C-sections have you had?(Required)

How many miscarriages have you had?(Required)

Please give us further explanation regarding your previous miscarriage(s)

-How many weeks gestation? -What year was it? -Was a D&E or D&C required?

How many years have passed since you last gave birth?(Required)

Are you currently married?(Required)

Yes

Do you smoke?(Required)

Yes

What method of birth control do you currently use?(Required)

Have you ever suffered or currently suffer from alcoholism?(Required)

Yes

Have you ever suffered or currently suffer from drug addiction?(Required)

Yes

Have you suffered from a mental health disorder, such as depression?(Required)

Yes

Please further explain your mental health history.

-What is situational? -What was the duration? -When did it occur? -Was it related to childbirth? -Level of severity? -Did you ever received treatment such as talk therapy or medication?

Are you currently taking medication to treat depression or anxiety?(Required)

Yes

Please list all medications you are currently taking.

In the last 12 months have you used any illicit substance? (including marijuana – even if legal in your area)(Required)

Yes

Please further explain illicit substance usage.

-Which substances have been used? -Are you still currently using this substance or substances. If not, when did you discontinue? -Are you willing to discontinue usage to become a gestational carrier? PLEASE NOTE: THE FDA REQUIRES DRUG SCREENING. EVEN IF A SUBSTANCE IS LEGAL IN YOUR AREA, USAGE WILL MAKE YOU INELIGIBLE TO BECOME A SURROGATE.

Have you ever had or currently have any type of diabetes?(Required)

Yes

Please elaborate on your diagnosis of diabetes.

-Type I or II or gestational diabetes? -Information regarding onset. -Treatment

Have you ever had or currently have hypertension?(Required)

Yes

Please further explain your diagnosis of hypertension.

Did you ever have preeclampsia or eclampsia during pregnancy?(Required)

Yes

Please further explain your history of preeclampsia or eclampsia.

-Date of occurrence -treatment -severity

Did you ever bleed during pregnancy?(Required)

Yes

Please elaborate on your history of bleeding during pregnancy.

Did you ever deliver preterm?(Required)

Yes

Before 37 weeks?

Please elaborate on your history of preterm birth.

-How many weeks gestation was your delivery -Were there any complications that arose from your preterm birth? -Have you delivered preterm more than once?

Is there any other medical issue you are aware of that might affect a future pregnancy?(Required)

Yes

Possibly

Please explain the issue you think may affect a future pregnancy.

We’re happy to talk you through whatever the issue may be.

Have you or your partner ever been arrested or convicted of a crime?(Required)

Yes

Please elaborate on criminal history

-Does the history pertain to you, your partner, or both? -Please list offenses, situations, and dates.

Level of Education(Required)

High School Diploma or GED

Associate’s Degree

Bachelor’s Degree

Master’s Degree

Advanced Degree

Are you currently employed?(Required)

Yes

If currently employed, what is your occupation?

Are you currently receiving welfare, using Medicaid, or supplemental security income (SSI)?(Required)

Yes

Please list which government assistance programs you currently receive benefits from.

Do you currently have health insurance?(Required)

Yes

Who is your insurance provider?

-Tricare? -United Health Care? -Cigna? -BlueCross BlueShield? -Etc

COVID-19 Vaccination Status?

Partially Vaccinated

Fully Vaccinated

Fully Vaccinated & Boosted

Unvaccinated, but willing to vaccinate if requested by IVF Clinic or Intended Parent(s)

Unvaccinated and unwilling to vaccinate

What is your ideal compensation?(Required)

Typical compensation rates for first time surrogates is generally between $40k-$70k depending on a number of factors. Previous surrogate compensation rates are typically higher.

What is your blood type?(Required)

Where did you hear about Elevate?(Required)

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.