Become a Surrogate Today in South Carolina

Step 1 of 8

CONTACT INFORMATION
Carrier’s legal name:
Carrier’s nickname, if any:
Spouse’s legal name (if applicable):
Spouse’s nickname, if any (if applicable):
Home Address:
Home Phone
Carrier’s cell phone:
Spouse’s cell phone:
Carrier’s email address:
Spouse’s email address:

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IDENTIFYING INFORMATION
Height:
Weight:
Ethnicity (e.g. AA, Asian, Hisp.):
Religion:
Marital Status:
- Married
- Single
- Divorced
- Living Together
If married, how long?
Please list all previous marriages and/or divorces, if any:
Describe Carrier’s personality, interests, and hobbies:
Describe Spouse’s personality, interests, and hobbies:

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BACKGROUND INFORMATION
Carrier’s date of birth:
MM slash DD slash YYYY
Spouse’s date of birth:
MM slash DD slash YYYY
Carrier’s SSN:
Spouse’s SSN:
Carrier’s Driver’s License #:
Spouse’s Driver’s License #:
US Citizen:
- Yes
- No
How long have you lived at your current address?
Do you rent or own?
List any other adults residing in the home:
Will all adults agree to a background investigation?
Describe any mental health treatment (including counseling) received by any member of the household:
Describe any civil lawsuits, arrests, criminal charges, and/or convictions (including DUI) a member of the household has been involved in:
Please describe any forms of state aid (e.g. Medicaid, foodstamps, etc.) you are receiving:
Do you have medical insurance?
- Yes
- No
If so, does it provide maternity coverage?
- Yes
- No
Have you ever been denied insurance coverage?
- Yes
- No
Please provide policy name, group number, and member ID number:
Policy Name Group No Member ID

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EDUCATIONAL BACKGROUND
Did you graduate from high school (if yes, list year)?
If no, did you obtain your GED (if yes, list year)?
If no, what was the highest grade level that you completed?
Did you attend college?
If yes, did you graduate (if so, list year and degree)?
List all colleges attended, including years and course of study:
College Name Year of Sudy Course of Study

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CARRIER’S EMPLOYMENT HISTORY
SPOUSE’S EMPLOYMENT HISTORY (if married)
Do you currently work?
- Yes
- No
Do you currently work?
- Yes
- No
Employer:
Employer:
Position/Title:
Position/Title:
Wage/Salary:
Wage/Salary:
Length of time at current job:
Length of time at current job:
Describe any maternity leave and/or disability leave you are entitled to receive (if any):

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PREGNANCY AND FERTILITY BACKGROUND
Please list the names and ages of each child you have given birth to:
Are any of the children the result of a previous gestational carrier (surrogacy) arrangement?
- yes
- no
Explain
Are all children in your custody?
- yes
- no
Explain
Are any of the children adopted or in foster care?
- yes
- no
Explain
Total number of pregnancies (include years):
Total number of live births and their corresponding years:
Total number of stillbirths (include years):
Total number of miscarriages (include years):
Total number of pregnancy terminations (abortions) (include years):
Describe any complications with any pregnancy (e.g. pre-eclampsia, anemia, gestational diabetes, high blood pressure, bedrest, etc.):
Children born via c-section:
Children born prematurely:
Do you want to have additional children and, if so, when?
Are your menstrual cycles regular?
Describe how many days you have between and how long a cycle typically lasts:
Date of your last pap smear:
Describe any method of birth control you are currently using:
Describe any treatment you or your spouse have received for herpes, hepatitis, venereal warts, chlamydia, HIV, syphilis, or any other sexually transmitted disease:
If you have been a carrier/surrogate previously, please describe:
If you have donated ova/eggs previously, please describe:
Please list any other agency or program to which you have submitted your application and when submitted:

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Thompson Dove Law Group

15 hours ago

Before you even contact us to begin your surrogacy process in South Carolina, you can read our preliminary requirements for surrogacy below to understand whether you might be a good fit for our Gestational Carrier Program.⁣⁣Here’s what we ask of all prospective surrogates:⁣⁣- Be between the ages of 21 and 38 years (over 38 may be considered if you’ve had a recent pregnancy)⁣- Have given birth to a child that you are raising⁣- Be financially stable and not on any form of government assistance⁣- Have a healthy pregnancy history and lifestyle⁣- Be smoke- and drug-free⁣- Be a U.S. citizen (or permanent resident) and speak English fluently⁣- Have a vehicle and valid driver’s license⁣- Reside in South Carolina (or within a one-hour drive of the S.C. border)Read the rest of the requirements here:tdlawgroup.com/home/surrogacy-and-assisted-reproduction/become-a-surrogate/requirements-to-be-a-s... ...

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Step 1 of 8

CONTACT INFORMATION

IDENTIFYING INFORMATION

BACKGROUND INFORMATION

EDUCATIONAL BACKGROUND

CARRIER’S EMPLOYMENT HISTORY

SPOUSE’S EMPLOYMENT HISTORY (if married)

PREGNANCY AND FERTILITY BACKGROUND

HEALTH HISTORY

PERSONAL NARRATIVES

Spartanburg Office

Thompson Dove Law Group

Rock Hill Office

Thompson Dove Law Group

Charleston Office

Thompson Dove Law Group

College Name	Year of Sudy	Course of Study

Step 1 of 8

CONTACT INFORMATION

IDENTIFYING INFORMATION

BACKGROUND INFORMATION

EDUCATIONAL BACKGROUND

CARRIER’S EMPLOYMENT HISTORY

SPOUSE’S EMPLOYMENT HISTORY (if married)

PREGNANCY AND FERTILITY BACKGROUND

HEALTH HISTORY

PERSONAL NARRATIVES

Contact Our Spartanburg Office

Contact Our Rock Hill Office

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