Surrogate Contact

We can’t wait to talk to you! Becoming a surrogate is a life-changing experience. Because of you, two intended parents will fulfill their dreams of starting a family. You deserve to feel supported, hopeful and confident on this journey. Our goal is to give you all of that and more.

Here’s what will happen when you finish this short form:

You’ll receive an email confirming if you qualify for our program.
Someone from our team will reach out.
We’ll get to know you and talk about your goals.
We’ll figure out the best way for us to serve you!

Contact Info

I would like to receive info / be contacted by (check at least one)

Phone Mail Email Text

First Name: Last Name: Email Address: Phone:

area code

-

phone number

Best Day/Time to Call:

Your current residential address

Street Address: City: State: Zip: Country:

Tell us a little about yourself

What is your Citizenship? (Select U.S. if dual-citizenship including U.S.) What is your Date of Birth? How many births have you had?

How many of those births were via cesarean? What is the date of birth for the last child you delivered? Have you experienced any complications during the pregnancy?

Yes No

Do you smoke?

Yes No

Height ft in Weight lb If you have had anti-depressant/anxiety medications in the last 12 months, please tell us the approximate last date you had it. Have you ever been convicted of a felony?

Yes No

Do you need help finding Intended Parents?

Yes, I need matching services to find intended parents

No, I am planning to be a gestational surrogate for a family member or friend

Is the family member or friend working with a clinic?

Yes No

Are you receiving any government assistance?

Yes No

Additonal Comments:

or contact us at 1-800-875-BABY (875-2229) now

*All of your information will be kept strictly confidential. You can read our privacy policy here.

Request Free Information Why Choose American Surrogacy?How to Become a Surrogate Surrogate Compensation What is Surrogacy Like?Am I Ready for Surrogacy?Requirements for Surrogates Surrogacy Medical Process Minimizing Surrogacy Risks How to Be a Good Surrogate Mother Explaining Surrogacy to Your Kids