Private Label Surrogacy - Donor Questionnaire

Become a Surrogate
with Private Label Surrogacy

Estimated completion time:
3-5 minutes

Thank you for your interest in becoming a surrogate! The application process consists of two phases:

1) The Prescreen Questionnaire (complete below): This is a short questionnaire that screens you on basic surrogacy qualifications. Once you pass this stage of the application process, you will be prompted to complete the full questionnaire.

2) Full Questionnaire: Once you submit this short prescreen questionnaire and it is accepted, you will be prompted to complete the full-length questionnaire. The full questionnaire is a slightly more involved survey that dives into more detail on everyone's favorite topic - YOU! So to get started, sit back, relax and complete the pre-screen below.

Please note: Private Label Surrogacy will decline any surrogate who is receiving government assistance of any kind. We will also decline a potential applicant if she has a spouse/partner or child she is living with receiving government assistance such as food stamps, WIC, government housing or any government insurance even if the state of residence requires this. In order for a surrogate to pass the psychological screening and attorney review she cannot be assisted by the government. Any compensation received for the surrogacy will also eliminate her from receiving benefits. The government will not pay for the prenatal visits or delivery charges for a surrogate pregnancy.

These are guidelines that have been set by governing boards for assisted reproductive technology and we adhere to these per recommendation.

Already started an application?
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1) First Name *

2) Last Name *

3) What is your Birthday? *

4) What is your height? *

5) What is your weight? *

6) What is your primary phone number for phone calls, messages and text notifications? *

7) Can we text you using your primary phone? *

Yes No

8) What state do you live in? *

9) Are you a US Citizen and eligible to work? *

Yes No

10) How many healthy, live babies have you given birth to? *

11) What is your current marital status? *

Become a Surrogate
with Private Label Surrogacy

Estimated completion time:
3-5 minutes

Thank you for your interest in becoming a surrogate! The application process consists of two phases:

These are guidelines that have been set by governing boards for assisted reproductive technology and we adhere to these per recommendation.

Already started an application?
Click Here to Login

1) What birth control method(s) are you currently using? *


	None (Sexually Active)
	None (Not Sexually Active)
	Birth Control Pills
	Condoms
	Depo-Provera
	IUD
	Implanon
	Nexplanon
	Nuvaring
	Patch
	Spermacide
	Tubal Ligation
	Vasectomy
	Other

2) Are you or anyone in your household receiving government assistance (for example: Medicaid, Food Stamps, Public Housing, Social Security Income)? *

Yes No

3) What is your highest level of completed education? *

4) Do you smoke cigarettes? *

5) Do you vape? *

Yes No

6) Do you use marijuana products of any kind? *

7) How often do you consume alcoholic beverages? *

8) Have you ever been arrested? *

Yes No

9) Knowing that PLS requires our surrogates to have the COVID vaccine, are you currently vaccinated? *

Yes No

10) How did you hear about us? *

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Surrogate Questionnaire

Become a Surrogate with Private Label Surrogacy

Become a Surrogate with Private Label Surrogacy

Become a Surrogate with Private Label Surrogacy

Create your account

Become a Surrogate
with Private Label Surrogacy

Become a Surrogate
with Private Label Surrogacy