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Home
Intended Parents
Surrogacy Process
Programs & Services
Available Surrogates
Intended Parents FAQ’s
Intended Parents Inquiry Form
Estimated Expenses
Surrogates
Gestational Surrogate Process
Surrogate Requirements
Surrogate Compensation
FAQ’s for Surrogates
Surrogate Application
Intended Parents
About Us
Contact
Gestational Surrogate Process
Surrogate Requirements
Surrogate Compensation
FAQ’s for Surrogates
Surrogate Application
Referral Bonus Program
Minimum Requirement Questionnaire
Thank you for your interest in becoming a gestational surrogate with Dakota Surrogacy.
Please fill out this brief questionnaire to begin your surrogacy application process.
Click here to view just a few of our waiting IPs who are hopeful to have a baby in 2023!
Please enable JavaScript in your browser to complete this form.
Your Name
*
First
Last
Phone Number
*
Email
*
Address
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Are you a permanent resident and currently living in the U.S.A.?
*
Yes
No
Are you between 21 and 43 years of age?
*
Yes
No
Have you given birth to a child and are raising or raised that child?
*
Yes
No
Did you experience any complications during your pregnancy?
*
Yes
No
Do you have personal medical insurance?
*
Yes
No
Are you or anyone in your household currently receiving any form of government assistance (other than food stamps)?
*
Yes
No
If Yes, please describe the assistance being received and who is receiving the assistance:
Do you currently smoke?
*
Yes
No
Is your BMI currently 31 or higher?
*
Yes
No
Have you given birth 6 or more times?
*
Yes
No
Have you previously had 3 or more c-sections?
*
Yes
No
Have you previously been diagnosed with Pre-Eclampsia?
*
Yes
No
Have you previously been diagnosed with Gestational Diabetes?
*
Yes
No
COVID-19 vaccination status?
*
Vaccinated
Unvaccinated
If you are currently unvaccinated, do you plan to get vaccinated for Covid-19 in the future?
Please share any additional information below.
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