Surrogacy Program NYC

Surrogate Questionnaire


Any questions, please call 855-241-2644

Email responses to contact@nbsurrogacy.com

All information on this application will be kept confidential, however this information will be shown to the Intended Parents, psychologists and the Intended Parent's physicians.


Personal Information

Yes No

Health/Medical Information:

Yes No

Health Insurance Company (Provide Name, Address and Phone Number)

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No N/A
Yes No
Yes No
Yes No

Click Here

OB-GYN/Hospital Information

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No Unsure

Sexual History

Yes No
Yes No
Yes No
Please Choose one:
Yes No
Yes No

Employment Information

Yes No
Yes No N/A
Yes No

Educational History

Please Choose the highest level attained (choose only one):

Background Information

Have you or your spouse/partner ever been arrested/convicted of a crime?(*)

Yes No N/A

Have you or your spouse/partner ever served time in jail?(*)

Yes No N/A

Do you have a valid driver’s license?(*)

Yes No

Does partner/spouse have a valid driver’s license?(*)

Yes No N/A

General Questions

Yes No
Yes No N/A
Yes No
Yes No
Yes No
Yes No