Apply to Become a Surrogate Part 2 "*" indicates required fields Name First Last Email* Street address City State Zip Code It's ok to leave a message? Yes No Ethnicity Natural hair color Height Weight BMI Martial StatusMartial StatusSingleMarriedDo you drink more than once a week? Yes No Have you smoked cigarettes in the past 3 months? Yes No Are you willing to take a nicotine screening test? Yes No Do you have medical problems?Have you completed high school? Yes No Are you currently a college student? Yes No Are you adopted? Yes No Maybe Number of siblings Only child 1 2 3 More than 3 College major? Do you have a college degree? Yes No Number of sexual partners in your lifetime Have you been an egg donor before?What type of birth control are you presently using? When was your last pap smear? Have you ever had an abnormal pap smear? Yes No I understand that a current pap (within 6 months) is required and that Simple Steps Fertility will be asking to receive a copy of my most recent pap results. I agree to send a copy of your recent pap results Not Applicable Have you or your partner tested positive for Chlamydia in the past 24 months? Yes No Have you or your partner tested positive for Gonorrhea in the past 24 months? Yes No Have you or your partner tested positive for Syphillis in the past 24 months? Yes No Have you ever been incarcerated? Yes No Are you willing to take a drug test? Yes No Have you ever used drugs such as marijuana, cocaine, heroin, ecstasy, LSD or methamphetamines? If so, please explain which drug, frequency of use, and last date used.Are you currently pregnant or breast feeding? Yes No Have you received a tattoo in the past 12 months? Yes No Have you traveled to a country in the past 24 months where you were advised / required to receive a malaria vaccine? Yes No Have you lived in or visited any of the following countries for 3 or more months between 1980 and 1996? * Channel Islands, England, Falkland Islands, Gibraltar, Isle of Man, Northern Ireland, Scotland or Wales Yes No Have you lived in any of the following countries for 5 or more consecutive years? Albania, Austria, Belgium, Bosnia / Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Kosovo (Federal Republic of Yugoslavia), Liechtenstein, Luxembourg, Macedonia, Montenegro (Federal Republic of Yugoslavia), Netherlands (Holland), Norway, Poland Portugal, Romania, Serbia (Federal Republic of Yugoslavia), Slovak Republic (Slovakia), Slovenia, Spain, Sweden, Switzerland, Turkey, Yugoslavia (Federal Republic includes Kosovo, Montenegro, and Serbia)? Yes No Are you or any of your biological family members registered with any Native American tribes? Yes No Are you currently enlisted in the Military? Yes No Submit a recent photograph of yourself. Applications with photographs submitted will be processed faster. Submit Photo I don’t have a photo to send at the moment. File* Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB. Consent* Click here if you agree to the above statement*Name First Last Enter the solution to the math problem below* Δ
