Becoming A Surrogate

Becoming A Surrogate

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姓名

电子邮箱

Phone Number

State

Zip code

Date / Time

年龄

Height(Feet)

BMI

Total number of deliveries

When is your last delivery?

Total number of c-sections?

Are there any complications of yourpreanancies? *

• Yes
• No

How often do you drink? *NeverVery rarelyonce a weekSecond ItemTwice a weekMore

Are you currently on any anxiety ordepression medications now? *YesNone

How often do you use tabaccoproducts? *NeverVery rarelyOnce a weekTwice a weekThree times or more a week

Have you consumed any drugs (e.g.THC, Marijuana, Heroin)? *YesNo

Are you U.S. citizen or PermanentResident? *

• U.S. citizen
• PermanentResident

Are you an experienced surrogate? *

• Yes
• No

Which is the best way to approachyou? *电子邮箱TextCall

When is best time to call you? *MorningAfternoonEvening

How do you know us? *Friends referralOneworld recruiterGoogleFacebookTiktokOthers

Do you have anyone referring you?

• Yes
• No

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