Surrogate Mother Registration 

Thank you for registering to become a Surrogate Mother. Your gift of pregnancy and childbirth helps a deserving couple to become parents. The information you provide in this application is kept confidential and used only for the purpose of matching you as a Surrogate Mother.  Diversity Fertility Services does not sell your information and takes measures to safeguard your confidentiality.

How May We Contact You?

Please ensure you meet the minimum requirements to be a Surrogate Mother by checking the applicable boxes below:

I understand that I am registering to learn more about the gestational surrogacy process and to potentially be matched as a Surrogate Mother by Diversity Fertility Services. 

I  confirm that I am a female between the age of 21-37 years and have no medical reasons why I cannot carry a baby for 40 weeks of pregnancy.

I  confirm that I have carried all of my pregnancies for over 37 weeks and all my births were uncomplicated with healthy newborn babies.

I confirm that I am healthy and do not have a family history of cancer or any type of chronic disease, depression, mental illness or personality disorders.

I confirm that I have not vaped, not juuled, not smoked a hookah, not used any form of tobacco, and have not used any form of opioid or recreational drugs within in the past year. 

I confirm that I have not spent more than 72 hours (3 days) in juvenile detention, jail or prison.

I confirm that I have not been diagnosed nor treated for drug addiction, sexual addiction or alcoholism.

New York/New Jersey

51 John F Kennedy Parkway, Short Hills, New Jersey 07078  *  toll-free (888) 569-7790       

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