• desk@ukrainiansurrogates.com
  • +380959017224

Surrogate Candidate Application

    Personal Information:




    Date of birth:




    Education:

    Specialty:

    Place of work:

    Position:

    Citizenship:

    Nationality:

    Passport data:





    Place of registration by passport:







    Place of permanent residence::







    Your place of birth:




    The registry office where your birth certificate was issued:






    Date of marriage:




    Name of husband:




    Husband's date of birth:




    If you are not married, are you in a civil marriage and for how long?

    Husband's education:

    Husband's specialty:

    Husband's place of work:

    Husband's position:

    Has your husband been charged in criminal offense?

    The consent of your husband and other family members to participate in the program:

    Your mobile phone:*

    Area code
    Number

    Husband's phone:

    Area code
    Number

    Home phone:

    Area code
    Number

    Your email address: *

    Housing and living conditions (type of apartment, house, rent, in private ownership):

    Living space:


    The number of people living in your place, full name, family ties:

    Height (cm):


    Weight (kg):


    Eye color:

    Hair color:

    You have a regular menstrual cycle:

    Duration of the menstrual cycle:

    Age when you started your menstrual cycle:


    Your character type:

    Your character traits:

    Religion:

    Foreign language skills:

    Have you been abroad?

    How many pregnancies have you had?

    Were there any surrogate among them?

    YesNot

    If you were an SM (surrogate mother) in which clinic, maternity hospital and in what year did you participate in the program?

    How many pregnancies have resulted in a live birth?

    Did any pregnancies end in miscarriages?

    Have you ever experienced complications during pregnancy or childbirth?

    Have you ever given birth by c-section? (what year):

    Have you ever terminated pregnancy?


    Have you had any problems planning pregnancy (could not get pregnant for more than 6 months?)

    Have you personally and your relatives had multiple pregnancies (twins, triplets)?

    1st child - date of birth:




    Have you ever terminated pregnancy?

    1st child - mode of delivery (childbirth):

    1st child at birth: Height / Weight:



    1st child - Apgar score, problems during pregnancy:

    2nd child - date of birth:




    2nd child - mode of delivery (childbirth):


    2nd child at birth: Height / Weight:



    2nd child - Apgar score, problems during pregnancy:


    3rd child - date of birth:




    3rd child - mode of delivery (labor):

    3rd child at birth: Height / Weight:



    3rd child - Apgar score, problems during pregnancy

    How many children do you have?

    Last child's age?:

    What diseases did your children suffer from?

    Do your children have chronic diseases? How and for how long, at what stage?

    Your blood type

    Type, Rhesus factor:

    Are you using any methods of contraception? If so, which ones and for how long?

    Gynecological diseases you had:

    Have you ever had a sexually transmitted disease (gonorrhea, syphilis, chlamydia, trichomoniasis, etc.)?

    Have you ever had a positive or uncertain response when tested for HIV, hepatitis B or C virus?:

    The presence of hereditary diseases, which one?

    The presence of chronic diseases, which one?

    Do you smoke tobacco?

    YesNoSometime

    Do you drink alcohol?:

    YesNoSometime

    Do you use drugs or antidepresants?

    YesNoSometime

    Have you had any type of surgery, including cosmetic surgery? What year, what exactly?:

    Have you received a blood transfusion? What year?

    Do you have any allergies? Which one, and what medications do you use?

    Are you taking any medications without a prescription? What kind? How often?

    Do you have tattoos, birthmarks, large moles?

    Are you currently suffering from or have been diagnosed or treated with anorexia or bulimia?

    Have you been registered with the phthisiatrician, psychiatrist, narcologist?

    Have you been registered with a psychiatrist?

    What is your reaction to stressful situations?

    How do you deal with stressful situations?

    Are you ready to be tested with a psychologist?

    Have you ever had criminal charges against you or your relatives and acquaintances?

    Do you have a car? If not, what transport do you use?

    Why do you want to become a surrogate mother?

    Where did you learn about surrogacy programs?


    Where did you learn about our agency?

    Your hobbies

    How do you feel about people who are infertile or have difficulty getting pregnant?:

    What qualities are crucial for you when choosing intended parents?

    What does it mean for you to be a surrogate mother?

    What pushed you to participate in the surrogacy program?

    What is your motivation?

    How do you see the surrogacy program and your participation in it?

    Do you understand that every surrogacy program is a fragile pregnancy that is supported only by medications?

    UnderstandI do not understand

    Are you ready to take the medications prescribed by your doctor according to the protocol?:

    ReadyNot

    Do you know how to make injections?

    YesNot

    Are you ready, if necessary, to lie in hospital bed for saving your pregnancy?:

    YesNot

    Who will look after your children when you are away?

    Are you ready to live in Kyiv in the last months of pregnancy?

    Desired compensation for the birth of a child, monthly compensation:

    Additional information (in this line you can indicate important information that you could not indicate in the questionnaire. Tell about yourself, your family, your life situation. Write a letter to your future intended parents. Perhaps you have any suggestions, comments, questions, you can indicate in this field:

    Make sure to attach your photos (face, full height) to the application form, additional photos with children and husband are welcomed.

    Photo 1:

    Photo 2:

    Photo 3:

    Photo 4:

    For any queries or assistance please call:

    +380959017224