Aurora ASI Surrogate

Welcome

Thank you for taking the first step toward one of the most beautiful and meaningful experiences. This form is designed to get to know you better and understand your motivation to be a surrogate mother. Through this process, we can help you change lives. Every answer is a step toward a future full of hope. Your information is confidential and will help us provide you with the best guidance.

Personal Information

First Name(s)

Paternal last name

Maternal last name

Date of birth

Mobile Phone

Email address

Personal and Contact Details

Place of Birth

Nationality

Marital Status

Education (last degree of studies)

Current Occupation

Religion

Demographic Information and Lifestyle

Parents' Country of Origin

Blood Type

Height (m)

Weight (kg)

Build

Race/Ethnicity

Eye Color

Natural Hair Color

Natural Hair Texture

Dominant Hand

Do you smoke?

Do you drink alcohol?

Have you used illicit drugs?

Do you have tattoos or piercings?

Do you exercise regularly?

Fertility and Obstetric History

Number of Pregnancies

Number of Deliveries (live births)

Number of C-sections

Number of Abortions (spontaneous or induced)

Briefly describe the evolution of your pregnancies, deliveries, or C-sections:

Have you previously participated as a surrogate?

Describe the experience and the outcome (if you have participated before)

Medical and Health History

Do you have any allergies?

Describe the allergy

Have you had any serious or chronic illnesses?

Describe the illness

Are you taking any medication regularly?

Describe the medication

Have you had any surgery?

Describe the surgery and approximate date

Have you had any recent dental problems?

Describe the dental problems

Do you have or have you had any ear problems?

Describe the ear problems

Do you wear glasses to correct your vision?

Describe the condition

How many sexual partners have you had in total?

Have you had any sexually transmitted diseases (STDs)?