Rocky Mountain Surrogacy, LLC

(208)284-7748 Fax-208 906-8554

Gestational Carrier Application

ALL INFORMATION ON THIS APPLICATION WILL BE KEPT CONFIDENTIAL; HOWEVER THIS INFORMATION WILL BE SHOWN TO THE INTENDED PARENTS, PSYCHOLOGISTS, AND PHYSICIANS

NAME______D.O.B______

SPOUSES FULL NAME______DOB______

ADDRESS______

HOW LONG HAVE YOU LIVED AT THIS ADDRESS?______

CELL PHONE NUMBER______

EMAIL ADDRESS ______

OCCUPATION ______WORK NUMBER______

EMPLOYERS NAME AND ADDRESS ______

EMERGENCY CONTACT______

THE FOLLOWING INFORMATION WILL BE SHOWN TO ALL INTENDED PARENTS

FIRST NAME ONLY ______D.O.B______

OCCUPATION ______Monthly Income______

HEIGHT/WEIGHT______RACE______ARE YOU A U.S CITIZEN______

WHAT IS YOUR MARITAL STATUS? ______City/State______

FIRST NAME OF PARTNER______DOB______

DO YOU HAVE CHILDREN TOGETHER? ______

NAMES / SEX / AGES / TYPE OF DELIVER / LENGTH OF PREGNANCY

WOULD YOU LIKE TO HAVE MORE CHILDREN IN THE FUTURE? ______

RELIGIOUS BACKGROUND______DO YOU PRACTICE? ______

DO YOU HAVE ANY COUPLES OR INDIVIDUALS THAT YOU WILL NOT BE WILLING TO WORK WITH?______

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HAVE YOU APPLIED TO ANY OTHER AGENCIES? ______

HOW DID YOU HEAR ABOUT US?______

HEALTH HISTORY

NOTE: MANY CLINICS WILL REQUIRE YOU TO SEND YOUR LABOR AND DELIVERY RECORDS FROM THE HOSPITAL AND YOUR PRENATAL RECORDS FROM YOUR OB/GYN FOR ALL BIRTHS. PLEASE START REQUESTING THESE AT THIS TIME

DO YOU CURRENTLY HAVE HEALTH INSURANCE? ______WHAT IS YOUR DEDUCTIBLE?______

WHAT IS YOUR MAX OUT OF POCKET?______IS IT THROUGH AN EMPLOYER_____

WHAT INSURANCE PROVIDER DO YOU HAVE?______

ALLERGIES______DO YOU HAVE ANY MEDICAL CONDITIONS? ______

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DO YOU TAKE ANY MEDICATIONS AT THIS TIME? AND WHY ______

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NUMBER OF PREGNANCIES_____ LIVE BIRTHS______MISCARRIAGES______ABORTIONS______

DELIVERY DATE / SEX / BIRTH WEIGHT / WEEKS / TYPE OF MEDS

IF YOU EXPERIENCED A MISCARRIAGE PLEASE STATE THE DATE AND HOW FAR ALONG YOU WERE______

______ARE YOUR MENSTRUAL PERIODS REGULAR? ______HOW LONG IS YOUR CYCLE?______

HOW WOULD YOU DESCRIBE ANY CRAMPING YOU HAVE DURING YOUR PERIOD?______

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IS THERE ANYTHING UNUSUAL ABOUT YOUR CYCLE? PLEASE EXPLAIN______

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ARE YOU CURRENTLY USING BIRTH CONTROL?______WHAT TYPE______

DO YOU SMOKE?______DOES ANYONE IN YOUR FAMILY SMOKE?______

HAVE YOU EVER USED ILLEGAL DRUGS?______

DO YOU HAVE A CRIMINAL RECORD? ______

DO YOU HAVE A HISTORY OF ANY EATING DISORDERS?______

WOULD YOU BE WILLING TO UNDERGO AN AMNIOCENTSIS?______

WOULD YOU BE WILLING TO TERMINATE OR ABORT IF THE INTENDED PARENTS CHOOSE TO?______

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WHAT REASONS WOULD YOU NOT REDUCE OR TERMINATE______

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WOULD YOU BE WILLING TO TERMINATE IF THE PREGNANCY WOULD RESULT IN A CHILD WITH DOWN SYNDROME?______

WOULD YOU BE OPEN WITH WORKING WITH A COUPLE THAT HAS GENETICALLY TESTED EMBRYOS KNOWING THAT THE LIKELIHOOD OF CARRYING A CHILD WITH DOWNS IS LESS THAN 10%______

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WHAT SURGERIES HAVE YOU HAD AND WHEN?______

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HAVE YOU RECEIVED ANY TATTOOS IN THE LAST SIX MONTHS?______

HAVE YOU BEEN SEEN BY A PROFESSIONAL FOR MENTAL ILLNESS?______

HAVE YOU EXPERIENCED ANY POST PARTUM DEPRESSION? ______

HAVE YOU BEEN PRESCRIBED OR TAKE ANY MEDICATION FOR MENTAL ILLNESS?______

HAVE YOU HAD ANY PROBLEMS WITH DRUGS OR ALCOHOL?______

BLOOD TYPE?______Rh FACTOR?______

NUMBER OF MONTHS BETWEEN STOPPING BIRTH CONTROL AND CONCEPTION?______

HAVE YOU DELIVERED ANY CHILDREN WITH BIRTH DEFECTS?______

SEXUAL HISTORY

ARE YOU WITH A SEXUAL PARTNER NOW? ______

DO YOU CURRENTLY HAVE MORE THAN ONE SEXUAL PARTNER? ______

HOW MANY SEXUAL PARTNERS HAVE YOU HAD IN THE PAST 3 YEARS?______

HAVE YOU HAD A SEXUALLY TRANSMITTED DISEASE IN THE LAST 3 YEARS?______

EDUCATIONAL HISTORY

WHAT IS THE HIGHEST LEVEL OF EDUCATION YOU HAVE COMPLETED______

WHAT DEGRESS OR OTHER TRADE EXPERIENCE YOU HAVE ______

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GENERAL QUESTIONS

BRIEFLY EXPLAIN YOUR UNDERSTANDING OF WHAT BEING A GESTATIONAL CARRIER WILL ENTAIL______

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PLEASE DESCRIBE YOURSELF______

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WHAT QUALITIES WOULD CONSIDER MOST IMPORTANT THAT THE INTENDED PARENTS HAVE______

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WHY HAVE YOU DECIDED TO BECOME A GESTATIONAL CARRIER?______

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WOULD YOU ALLOW THE INTENDED PARENTS IN THE DELVERY ROOM? ______

WOULD YOU ALLOW THE INTENDED PARENTS TO ATTEND DOCTOR APPOINTMENTS?______

WOULD YOU BE WILLING TO PUMP OR FREEZE BREAST MILK?______

HAVE YOU BEEN EVER AN EGG DONOR______

HAVE YOU EVER BEEN A GESTATIONAL CARRIER BEFORE? IF YES PLEASE EXPLAIN YOUR EXPERIENCE__

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WHAT IS YOUR FINANCIAL EXPECTATIONS FOR BEING A GESTATIONAL CARRIER? ______

HAVE YOU EVER PLACED A CHILD UP FOR ADOPTION?______ARE YOU ADOPTED?______

HOW DO YOU FEEL ABOUT CARRYING MULTIPLES? TWINS OR TRIPLETS?______

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HOW MUCH CONTACT DO YOU WANT FOLLOWING BIRTH?______

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DO YOU FEEL CONFIDENT THAT YOU WILL BE ABLE TO GIVE THE COUPLE THEIR CHILD OR CHILDREN____

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WHAT TYPE OF SUPPORT SYSTEM DO YOU EXPECT TO HAVE THROUGH THIS EXPERIENCE______

ALL INFORMATION PROVIDED IN THIS APPLICATION IS TRUE, ACCURATE,AND COMPLETE AND TO THE BEST OF MY KNOWLEDGE.

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GESTATIONAL CARRIER DATE

I BELIEVE MY WIFE/PARTNER S RESPONSE TO THIS APPLICATION IS TRUE, ACCURATE AND COMPLETE TO THE BEST OF HER KNOWLEDGE. I AM IN SUPPORT OF HER DESIRE TO BECOME A GESTATIONAL CARRIER.

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SIGNIFICANT OTHER/HUSBAND DATE

I,______(the ‘Gestational Carrier’ hereby acknowledge that

A. Rocky Mountain Surrogacy, LLC did not induce, coerce me in my decision to become a gestational carrier

B. Rocky Mountain Surrogacy, LLC is not a party to my agreement with the Intended Parents

C. Rocky Mountain Surrogacy, LLC will be providing this application to potential parents both through hard copy and electronic formats. I acknowledge and agree that I will not be notified of such mailings and herby consent to the distribution of my application and photos to potential parents via mail and through electronic media such as email.

D. Therefore, I hereby agree to release and discharge Rocky Mountain Surrogacy, LLC and any of its representatives, agents, employees, and servants from all liability and all manners of action, suits, causes of actions, proceedings, debts, contracts, judgments, damages, claims, and demands whatsoever in law or equity in connection with my decision to become a gestational carrier or any adverse consequences which may arise in my connection with or as a result of my participation with this process. I hereby further agree to indemnify Rocky Mountain Surrogacy, LLC against any and all costs incurred in defending any such actions arising of this process. In the event that testing or screening has been completed and I choose not to move forward with the process I understand that any fees incurred on my behalf is my responsibility.

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Applicant Date

Authorization to Release Protective Health Care Information

PATIENT NAME______SSN______

DOB______PHONE NUMBER______

I hereby consent and Authorize______(health facility name) to Release to Rocky Mountain Surrogacy, LLC 2238 N Astaire Way Meridian, Idaho 83646 Protected health information concerning any and all ob/gyn history for the above patient. I understand that this information may include but not limited to-

Discharge Summary Operative Reports Pap Results

History and Physical Anything Relevant to previous pregnancy history

The purpose of releasing this information is for the application and approval to be a gestational carrier.

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Signature of Patient Date

This consent will automatically expire 90 days of signature unless another date is specified below.