Surrogate Application Form
A special message to prospective surrogate moms before completing the form below:
 
If you are considering the prospect of surrogacy, carrying a baby for some one who cannot, please find more information on being a surrogate and aspects pertaining to surrogacy legislation, on this site.
 
Kindly complete the application form below or download this version and return to info@baby2mom.co.za or fax 086 503 3831. Please note the form will only be submitted once the "send application form" button at the bottom is entered.
 
 
 
Confidential Information
 
 
Full Name
 
Identity Number
 
Where do you live?
 
Where did you hear about baby2mom?
 

Confidential Contact Information
 
 
Home Tel
 
Work Tel
 
Mobile (cell) number
 
Alternate Contact
 
Email
 
Preferred Contact Method
 

Confidential Reproductive Information
 
 
Details of contraceptives
 
Are you a virgin?
 
Ever miscarried?
 
Are you sexually active?
 
Have you had any uterine operations?
 
When last did you see your gynae?
 
Are you at risk of carrying any sexual diseases?
 

Initial Information
 
 
How old are you?
 
Year of birth
 
What nationality are you?
 
What race are you?
 
Blood group
 

Surrogacy Motivation
 
 
Why do you want to be a surrogate
 
What prompted this decision?
 
What type of relationship do you anticipate with the commissioning parent during and after the surrogacy?
 
Are you wanting a relationship with the child conceived of surrogacy?
 

Surrogacy History
 
 
Details of previous surrogacies
 
Did you sign an agreement?
 
Did you have an embryo transfer?
 
Did you conceive?
 
After how many attempts did you conceive?
 
Was the baby born full term?
 
How did you feel about the surrogacy?
 
Gestational or traditional surrogacy?
 
Where you psychologically assessed?
 

Reproductive Information
 
 
How many children do you have?
 
How old are they?
 
Types of Birth
 
Any complications during the pregnancy or at birth?
 
Did your carry your child(ren) full term?
 

Health of Surrogate
 
 
Fertility problems
 
Weight and Height?
 
Have you ever been diagnosed with any medical concerns?
 
Any psychological illnesses – bipolar, depression, schizophrenia, or other?
 
Have you ever been declined for a surrogate program?
 
Current health status
 
Alcohol intake
 
Any history of substance or alcohol abuse?
 
Have you had any addiction or substance abuse problems?
 
Do you partake in recreational drugs?
 
Are you on any medication?
 
If you are on any medication, will you be willing to change this for the duration of the surrogacy?
 
Are you a smoker?
 
If you are a smoker, are you willing to cut down or stop during the surrogacy? Please specify.
 
Any comments/ notes regarding your health?
Do you have:

*Diabetes

 

*Cholesterol

 

*Genetic issues

 

*High or low Blood Pressure

 

*Cancer

 

*Tay Sachs

 

*Hemophilia

 

*Porphyria

 

*Any physical handicaps

 

*Asthma

 

*Current diseases

 
When last did you see a doctor?
 

Social Information
 
 
Are you married or in a relationship?
 
Where you married before?
 
Will your partner support surrogacy?
 
Do you have another support structure?
 
Are you on a medical aid?
 
Do you have your own transport?
 
How many people live in your household?
 
How would you describe your home environment?
 

Personal Information
 
 
How would you describe your personality
 
Please advise what you do for a living
 
Will your employer support surrogacy?
 
What is important to you in life?
 
Do you understand that you will be giving the baby to the commissioning parents after birth?
 

Surrogacy Stipulations
 
Will you be a surrogate mom for a single person?
 
Will you be a surrogate for a person of different race to you?
 
Will you be surrogate for a gay couple?
 
Do you have any religious criteria about surrogacy?
 
Are you expecting a donation for loss of income earned? If yes, please give an indication of your expectations.
 
What is your ideal type of birth for a surrogacy pregnancy?
 
Will you consider being a traditional surrogate – where you donate your eggs as well? If yes, please proceed to answer the next questions:
 

Physical Profile – only if you will consider being a traditional surrogate
(surrogate and egg donor for the same intended parent)
 
 
Race
Skin Complexion
Height
Weight
Eye colour
Natural hair colour
Hair texture
Build
Any other defining traits
Please can you send me a picture of yourself to info@baby2mom.co.za
Will you give consent for baby2mom to show your picture prior to introducing you to a potential intended parent

Surrogacy Process and Confirmation
Please confirm that you understand the following:
 
 

The most important screening of the commissioning parent is by you.

You will undergo a psychological and medical assessment

You will meet with the commissioning parent and confirm the terms of the surrogacy arrangement

The medical screening and scans in early pregnancy will be internal scans

A contract will need to be compiled between you and the commissioning parent

Court order approval is required prior to any fertility treatment taking place.

You will proceed with necessary legalities and recommended surrogacy attorneys as guided by baby2mom

Agree to keep Jenny (on info@baby2mom.co.za or 084 465 8353) updated with initial appointment with commissioning parent, blood tests, scans, psychological assessments

I will advise should my availability change

I agree to participate in the surrogacy programme and avail myself as guided and when I have agreed.

I agree to proceed with all surrogacy arrangements facilitated by baby2mom – including more attempts with the same IP (as per agreement with commissioning parents)

I agree to keep baby2mom updated with the embryo transfer related to the surrogacy

I agree that my application can be provided to necessary fertility clinics who are in contact with persons looking for potential surrogate mothers.

 

Confirmation (Yes Required)
All information provided is correct.
I agree to keep relevant persons updated wrt progress of the surrogacy screening
 
 
Thank you and bless you for your special help!
 
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