Prescreen | Surrogacy Institute of Hawaii

Thank you for your interest in becoming a surrogate with the Surrogacy Institute of Hawaii (SIH)! 

Choosing to become a surrogate is an incredibly generous and life-changing decision, and we’re so grateful you're considering this path. In recognition of your time and commitment, surrogates with SIH can earn a starting base compensation of $60,000+ while helping others build the family of their dreams. 

We welcome healthy women of all backgrounds who meet the following basic criteria:

• Ages 21–45

• History of at least one full-term, healthy pregnancy

• In good physical and mental health

• Non-smoker, drug-free, and free of infectious diseases 

SIH is Hawaii's only surrogacy agency directly partnered with a fertility clinic, the Fertility Institute of Hawaii. This means your journey is overseen from day one by a trusted team of reproductive specialists, not just agency staff.

Learn more about our program or contact us at [email protected].

First Name

Last Name

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Street Address

City

Country

State

Zip Code

Phone Number

Best time to contact you

Email

How would you prefer to be contacted?

Are you a US Citizen?

Are you legally residing and able to work in the United States?

Height

'

"

Weight

lbs

Are you employed?

Occupation

Employer

Total number of pregnancies

Total number of vaginal deliveries

Total number of c-sections

Any history of miscarriage?

Please explain history of miscarriage (including dates)

Do you have any history of stillbirth?

Please explain history of stillbirth (include date)

Any complications with past pregnancies?

Please explain

Are you currently breastfeeding?

Do you currently smoke or vape?

How many packs/day of cigarettes, or, how many times a day do you vape?

Are you willing to quit?

Do you drink alcohol?

How many drinks per week?

Do you have any past medical history?

Please list your diagnoses and dates of diagnosis

Any illicit drug use?

Which illicit drugs? How often do you use them?

Do you have any past surgical history?

Please provide details (include date(s) of procedure(s))

Have you ever been diagnosed with a mental health disorder or experienced significant mental health challenges?

Please provide details regarding any diagnosis you have received and currently are or have been treated for

Have you ever had any problems with alcoholism or drug abuse?

Please provide details about alcoholism or drug abuse.

How did you hear about us?

Which website?

Name of person who referred you

Name of clinic or doctor that referred you

Please provide referral source.