Gestational Carrier Initial Intake Form

1Contact Information
2PreQualification

First Name

Last Name

Do you have a middle name, and if so, what is it?

Have you ever gone by any other name, like a middle name, nickname or different last name?

Phone Number

Street Address

Country

City

State

Zip Code

Date of Birth (MM/DD/YYY)

Sun Mon Tue Wed Thu Fri Sat

What is your height?

What is your current weight?

lbs

Are you a U.S. Citizen or Permanent resident?

How many pregnancies have you had?

How many C-sections have you had?

Do you currently smoke or vape?

Do you currently use any recreational drugs?

Have you been diagnosed with a mental health disorder?

How did you hear about us?

Tell us why you want to be a surrogate.

Do you agree to receive text messages from GSHC Surrogacy & Egg Donation sent from 949-666-0216 and 949-666-7918? Message frequency varies and may include service updates or appointment reminders. Message and data rates may apply. Reply STOP at any time to unsubscribe. For assistance, reply Yes or contact us at 949-666-0216 or 949-666-7918. Calls may be recorded for internal training and quality assurance purposes.