Surrogate Application - Dakota Surrogacy

Your Name *

First

Last

Phone Number *

Email *

Address

City *

State *

Zip Code *

Are you a permanent resident and currently living in the U.S.A.? *

Are you between 21 and 43 years of age? *

Have you given birth to a child and are raising or raised that child? *

Did you experience any complications during your pregnancy? *

Do you have personal medical insurance? *

Are you or anyone in your household currently receiving any form of government assistance (other than food stamps)? *

If Yes, please describe the assistance being received and who is receiving the assistance:

Do you currently smoke? *

Is your BMI currently 31 or higher? *

Have you given birth 6 or more times? *

Have you previously had 3 or more c-sections? *

Have you previously been diagnosed with Pre-Eclampsia? *

Have you previously been diagnosed with Gestational Diabetes? *

COVID-19 vaccination status? *

If you are currently unvaccinated, do you plan to get vaccinated for Covid-19 in the future?

Please share any additional information below.