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Gestational Carrier Pre-Screening Application

This is a secure, HIPAA compliant form

Your information collected here will not be shared with any other party outside of
 
Marin Fertility Center

All medical/psychological information gathered is kept completely confidential
and is protected by state and federal regulations

** Nothing on this application is intended to create or imply a contractual relationship **

Gestational Carrier Pre-Screening Application

"*" indicates required fields

This field is for validation purposes and should be left unchanged.
MM slash DD slash YYYY
Are You Currently Married?
Are You Currently In A Sexual Relationship*
Are You Currently Raising A Child/Children?
1A. Have You Carried At Least One(1) Baby To Full Term?
1B. Have You Had A Miscarriage In The Past?
2A. Have You Experienced Medical Complications With Previous Pregnancies? (e.g. Preeclampsia, High Blood Pressure, Gestational Diabetes)
3. ​​​​ Have You Had More Than Five(5) Deliveries -- Regardless Of Outcome?
4. Have You Had More Than Three(3) Cesarean Sections?
5. Have You Been A Gestational Surrogate Before?
6. Do You Currently Live In A Safe, Stable, Family-Friendly Environment?
7. Do You Have Adequate Support From Others In Your Decision To Be A Gestational Carrier, And To Help Cope With The Pregnancy Should You Become One?
8. Do You Experience Frequent Periods Of Stress Or Anxiety?
9. Do You Acknowledge That There Are Possible Health Risks/Complications That Come With Being Pregnant? Which Could Possibly Lead To Prolonged Bed Rest Or Hospitalization?
10. Do You Have A History Of Any Sexually Transmitted Infections (STIs)?
11. ​​​​​ Would You Be Willing To Be Evaluated By A Mental Health Professional?
12. Would You Be Willing To Attend Counseling Sessions By A Licensed Professional, Possibly In Tandem With The Indented Parent(s)?
13. Would You Be Willing To Participate In Routine, Physical Health Examinations Performed By Our Physicians? (e.g. Pap Smear, Mammogram, etc.)
14. Would You Be Willing To Participate In A Test Screening For STIs, HIV, Or Other Acquired Infections That Might Be Transmissible To A Fetus?
15. Would Your Sexual Partner At The Time (If Applicable) Be Willing To Participate In A Test Screening For STIs, HIV, Or Other Acquired Infections That Might Be Transmissible To A Fetus?
16. Would You Be Willing To Submit A Urine Drug Test If Asked?
17A. Have You Received A Body Piercing Within The Past 12 Months?
MM slash DD slash YYYY
18A. Have You Received A Tattoo Within The Past 12 Months?
MM slash DD slash YYYY
19. Have You Received Your Titers For Varicella and Rubella?
20. Are You Up-To-Date On Your Other Vaccinations/Boosters?
21. Do You Drink More Than One(1) Alcoholic Drink Per Day, Or More Than Seven(7) Alcoholic Drinks Per Week?
22.​​​ Do You Currently Smoke Cigarettes?
23. Have You Smoked Cigarettes In The Past, Even If You Currently Do Not?
24. Do You Currently Use Any Kind Of Drugs Recreationally? Even If Only On Rare Occasions. (e.g. Marijuana, Nicotine, CBD Products, Vape, Mushrooms, etc.)
25. Do You Have A History Of Using Hard (Illicit) Drugs, Even If Just A One-Time Use? (e.g. Heroin, Cocaine, etc.)
26A. Do You Currently Participate/Maintain Any Personal Habits Or Lifestyle Choices That Could Potentially Be Harmful Or Dangerous To Yourself? (e.g. Motorcycle Riding, Poor Sleep Habits, Eat Excessive "Junk" Food, Little To No Physical Activity, etc.)
27. Would You Be Willing To Temporarily Change Or Alter Your Current Exercise Regimen/Level If Asked By The Intended Parent(s) Or Found Necessary By The Physician While Carrying?
28. Would You Be Willing To Temporarily Change Or Alter Your Current Diet/Food Preferences If Asked By The Intended Parent(s) Or Found Necessary By The Physician While Carrying?
29. Would You Be Willing To Temporarily Change Or Alter Personal Habits/Lifestyle Choices If Asked By The Intended Parent(s) Or Found Necessary By The Physician While Carrying?
30. Would You Be Okay To Openly Discuss And Disclose Your Personal Activities/Lifestyle Choices With The Intended Parent(s)? (e.g Travel, Exercise, Diet, Sexual Activity, etc.)
31. Do You Understand And Acknowledge That By Becoming A Gestational Carrier, You Are Agreeing To Participate And Commit To A Job For Upwards Of One(1) Year?
32. Would You Do Your Utmost Best To Follow And Respect The Wishes And Desires Asked Of You By The Intended Parent(s)?
33. Would You Be Willing To Travel Out-Of-State If Needed?
34. Will You Dedicate Yourself And Time To Attend All Appointments Made Regarding The Pregnancy?
35. Do You Acknowledge That By Becoming A Gestational Carrier, You Are Committing To A Job That Can Be Very Taxing Emotionally, Physically, and Mentally, And That You Won't Be Able To Quite Half-Way Through As There Are People Who Will Be Fully Relying On You To Help Build Their Family?

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