Surrogate Application

SURROGATE APPLICATION

NAME(Required)

First Middle Last

PREFERRED NAME / NICKNAME

EMAIL(Required)

PHONE NUMBER(Required)

CONSENT(Required)

By checking the box below, you consent to receiving certain mobile messages or calls from us regarding your application and other service-related information. Standard message and data rates may apply. You may unsubscribe at any time directly via SMS message or by updating your privacy preferences in your profile.

I agree to receiving text messages or calls at this number.

ADDRESS(Required)

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

U.S. CITIZENSHIP STATUS(Required)

DATE OF BIRTH(Required)

Month

Day

Year

More About You

WHAT IS YOUR ETHNICITY?(Required)

PRIMARY LANGUAGE(Required)

IF ENGLISH IS NOT YOUR PRIMARY LANGUAGE, DO YOU HAVE AN INTERPRETER WHO CAN ASSIST YOU THROUGHOUT THE JOURNEY?(Required)

Yes

This does not apply to me

HEIGHT(Required)

CURRENT WEIGHT(Required)

WHAT IS YOUR RELIGIOUS AFFILIATION, IF ANY?(Required)

HAVE YOU EVER BEEN CONVICTED OF A CRIME? IF SO, PLEASE LIST WHEN AND THE NATURE OF THE CRIME(Required)

DO YOU OR YOUR PARTNER CURRENTLY HAVE ANY OUTSTANDING LEGAL OBLIGATIONS (BANKRUPTCY, DIVORCE PROCEEDINGS, LAWSUITS, MISDEMEANOR, AND/OR CRIMINAL OFFENSES)?(Required)

Outstanding legal obligations can sometimes comprise a smooth surrogacy journey. Once we know your current situation, we can be better prepared and equipped to make sure your surrogacy journey is smooth and successful.

DO YOU OR YOUR PARTNER HAVE ANY PAST, CURRENT, OR ONGOING OPEN CASES WITH CHILD PROTECTIVE SERVICES? IF SO, PLEASE EXPLAIN SO WE CAN BETTER UNDERSTAND(Required)

DO YOU HAVE A VALID DRIVERS LICENSE?(Required)

WHAT FORM OF TRANSPORTATION DO YOU USE?(Required)

Public transportation, drive your own car, etc.

MARITAL STATUS(Required)

WILL YOU HAVE A PARTNER OR SPOUSE ON THIS JOURNEY WITH YOU?

Yes

HIGHEST LEVEL OF EDUCATION COMPLETED(Required)

ARE YOU CURRENTLY EMPLOYED?(Required)

Yes

IF CURRENTLY EMPLOYED, WHAT IS YOUR OCCUPATION?(Required)

ARE YOU CURRENTLY RECEIVING WELFARE, USING MEDICAID, OR SUPPLEMENTAL SECURITY INCOME (SSI)?(Required)

Yes

DO YOU HAVE HEALTH INSURANCE CURRENTLY?(Required)

Yes

WHAT IS YOUR COMBINED HOUSE HOUSEHOLD ANNUAL INCOME?(Required)

We need to make sure you are financially stable enough to support her own family and all her needs, even if receiving a stipend/allowance from the intended parents. We understand that every financial situation is different, so we want to know your personal situation.

Medical / Health History

DO YOU SMOKE CIGARETTES OR VAPE?(Required)

Yes

DO YOU USE DRUGS CURRENTLY? (MARIJUANA INCLUDED)(Required)

Yes

HAVE YOU EVER SUFFERED OR CURRENTLY SUFFER FROM ALCOHOLISM?(Required)

Yes

HAVE YOU EVER SUFFERED OR CURRENTLY SUFFER FROM DRUG ADDICTION?(Required)

Yes

IN THE LAST 12 MONTHS, HAVE YOU USED ANY ILLICIT DRUGS? (MARIJUANA INCLUDED - EVEN IF LEGAL IN YOUR STATE)(Required)

Yes

DO YOU OR HAVE YOU SUFFERED FROM A MENTAL ILLNESS, SUCH AS DEPRESSION OR BIPOLAR DISORDER? PLEASE EXPLAIN(Required)

ARE YOU CURRENTLY TAKING MEDICATION TO TREAT DEPRESSION OR ANXIETY?(Required)

Yes

PLEASE LIST ALL MEDICATIONS THAT YOU ARE TAKING CURRENTLY(Required)

DO YOU CURRENTLY OR HAVE YOU EVER HAD DIABETES?(Required)

Yes

DO YOU CURRENTLY OR HAVE YOU EVER HAD HYPERTENSION?(Required)

Yes

DO YOU THINK THERE IS ANY OTHER MEDICAL ISSUE YOU HAVE THAT MIGHT AFFECT A FUTURE PREGNANCY?(Required)

Yes

Maybe

IF YES OR MAYBE TO THE ABOVE QUESTION, PLEASE EXPLAIN WHAT ISSUE YOU THINK MAY AFFECT A FUTURE PREGNANCY(Required)

Luxe is more than happy to discuss whatever the issue may be.

COVID-19 VACCINATION STATUS(Required)

Partially vaccinated

Fully vaccinated

Fully vaccinated & boosted

Unvaccinated, but willing to vaccinate if requested

Unvaccinated and unwilling to vaccinate

WHAT IS YOUR BLOOD TYPE?(Required)

Sex / Reproductive Health History

ARE YOU ON ANY FORM OF BIRTH CONTROL? IF SO, WHAT KIND?(Required)

ARE YOU PREGNANT CURRENTLY?(Required)

We cannot work with women who are currently pregnant. However, we would love to discuss more and answer any questions you may have. Hopefully Luxe can work with you once you have finished your delivery and post-partum journey.

Yes

ARE YOU CURRENTLY BREASTFEEDING?(Required)

We recommend completing any breastfeeding goals prior to becoming a surrogate.

Yes

HOW MANY CHILDREN HAVE YOU GIVEN BIRTH TO?(Required)

HOW MANY YEARS HAS IT BEEN SINCE YOU LAST GAVE BIRTH?(Required)

HAVE YOU EVER GIVEN BIRTH TO MULTIPLES? (TWINS, TRIPLETS, ETC)(Required)

Yes

HOW MANY C-SECTIONS HAVE YOU HAD?(Required)

HAVE YOU EVER DELIVERED PRETERM? (BEFORE 37 WEEKS)(Required)

Yes

HAVE YOU EVER EXPERIENCED A STILL-BIRTH?(Required)

Per IVF clinic guidelines, we cannot work with women who have experienced a still-birth.

Yes

DID YOU EVER HAVE PREECLAMPSIA OR ECLAMPSIA IN A PAST PREGNANCY?(Required)

Yes

DID YOU EVER BLEED IN A PAST PREGNANCY?(Required)

Yes

HOW MANY MISCARRIAGES HAVE YOU HAD?(Required)

HAVE YOU BEEN A SURROGATE IN THE PAST?(Required)

Yes

HOW DID YOU HEAR ABOUT LUXE IVF?(Required)

HOW DO YOU WANT US TO REACH YOU?(Required)

WILL YOU PROVIDE YOUR INSTAGRAM/FACEBOOK USERNAME? IF SO, PLEASE LIST(Required)

PHOTO UPLOAD(Required)

Please upload a photo of yourself.

Max. file size: 512 MB.

TERMS AND CONDITIONS(Required)

I agree to the terms and conditions.

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