Application Forms – Afrinest Surrogacy Agency

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Start Your Surrogacy Journey

Take the first step toward making a life-changing impact. Complete the application form below so our team can review your details and guide you through the next stages of becoming a surrogate with Afrine St Surrogacy.

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Full Name *

want medical How

Date of Birth

Age

Phone

Email *

Hometown

Where do you live?

GPS Address

Occupation

Weight (Kilograms)

Height (in centimeters)

Marital Status

Single
Married
Divorced/ Seperated

Are you on any family planning method?

Yes
No

Have you been a Surrogate before?

Yes
No

What is your blood group?

A
B
AB
O

What is your genotype?

When did you have your menses three month ago? (State the date and month)

When did you have your menses two months ago? (State the date and month)

When did you have your menses last month? (State the date and month)

When was the last time you took the morning after pill (contraceptives)?

How many children do you have? *

Number of Cesarean Section (CS)

How old is your last child?

Childcare arranged during surrogacy?

Are you breast feeding?

Yes
NO

Do you have a Ghana Card or Passport?

Ghana Card
Passport

Are you a Ghanaian?

Yes
No

How did you hear about Afrinest-Surrogacy

Internet
Social Media
Referral

In your own words, explain what surrogacy is all about

Why do you want to become a surrogate?

What is Your Genotype?

AA
AS
SS
I am not sure

Emergency Contact Name

Relationship to You

Phone Number

Alternate Contact Number (if applicable)

Are you currently pregnant?

Yes
No

Would you agree to terminate a pregnancy for medical reasons if requested by the intended parents?

Yes
No

Please list any prescribed medications you are currently taking. (If none, please write “None.”)

Do you have any diagnosed or undiagnosed medical conditions?

Yes
No

If yes, please specify

Do you have any allergies? Please specify

Have you ever taken an HIV test?

Yes
No

If yes, when was your most recent HIV test?

Do you have a history of sexually transmitted diseases (STDs)?

Yes
No

Have you ever been diagnosed or treated for any sexually transmitted infections (STIs)?

Yes
No

If yes, please provide details including

1) Type of infection 2) Treatment received 3) Treatment method 4) Date of occurrence

Do you smoke or consume alcohol? Please indicate which applies

Smoke
Alcohol
Both
Neither

Do you have pets or live near pets in your home or neighborhood?

Yes
No

What is your highest level of education?

Surrogacy Preferences

Would you prefer to serve as

A Traditional Surrogate (using your own egg)
A Gestational Carrier (carrying an embryo created by the intended parents)
Either/Both

What is the minimum amount of compensation you would accept to participate in the surrogacy process?

Verification of Accuracy

I, __________________, hereby confirm that all the information provided in this Surrogate Profile form for Afrinest Surrogacy Agency Limited is true and accurate to the best of my knowledge. I understand that I am responsible for any false information given.

Full Name

Nationality ? *

Date

Signature

Clear Signature

Nurturing health with compassion, guiding your journey with expertise, and embracing every new beginning

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info@fertesahealth.com
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