Apply to Agency: Reproductive Assistance, Inc.

Reproductive Assistance, Inc.

You must answer all questions. In addition, this agency requires you to meet these criteria:

You are a US citizen or you are a legal resident of the US
You have not taken the Depo Provera contraceptive in the past 2 months
You have health insurance that does not have any surrogacy exclusions OR you live within 50 miles of Cincinnati, OH
You have not taken any anti-depressants in the past 6 months
You have never contracted a venereal disease, ovarian or uterine cysts, polyps, or tumors
You have never been convicted of a crime
You and your spouse do not smoke or use illegal drugs
You are not currently receiving any kind of government assistance
You have delivered a child in the past 5 years without any complications during the pregnancy or birth
You will authorize an agreement to be a surrogate exclusively with Reproductive Assistance, Inc. for at least 60 days
You agree to respond to Reproductive Assistance, Inc.
All information provided is true to the best of your knowledge
You are committed to becoming a surrogate.
Must be a resident of one of these states: OH

Contact Information
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Are You an Experienced Surrogate?:

Tell Us About Yourself
Age:	years
Height:	feet inches
Weight:	pounds

Are you a US citizen or a legal resident of the US?
Have you taken the Depo Provera contraceptive in the past 2 months?
Do you have health insurance that does not have any surrogacy exclusions OR do you live within 50 miles of Cincinnati, OH?
Have you taken anti-depressants in the past 6 months?
Have you ever contracted a venereal disease (herpes, syphilis, chlamydia), ovarian or uterine cysts, polyps, or tumors?
Have you ever been convicted of a crime?
Do you or your spouse smoke or use illegal drugs?
Are you currently receiving any kind of government assistance?
Have you delivered a child in the past 5 years without any complications during the pregnancy or birth (i.e. no gestational diabetes, hypertension, hospitalization/bedrest, only one prior C-section, etc.) with a single child resulting after 38 weeks or twins after 36 weeks?
If you qualify to become a surrogate with Reproductive Assistance, Inc., will you authorize an agreement to become a surrogate exclusively with Reproductive Assistance, Inc. for at least 60 days?
A representative from Reproductive Assistance, Inc. will be contacting you. Do you agree to respond to Reproductive Assistance, Inc.?
All information that you have provided will be verified and your survey submission will be taken as a serious entry toward becoming a surrogate. If you are not serious about becoming a surrogate, please do not submit this form. Simple inquiries are addressed on the Frequent Questions tab. Is all information presented above true to the best of your knowledge?
Are you committed to becoming a surrogate? (If "No", please contact Reproductive Assistance directly.)

What is your most important question or concern about becoming a surrogate mother?

Learn More About Becoming a Surrogate Mother

Reproductive Assistance, Inc.

Contact Information

Tell Us About Yourself

What is your most important question or concern about becoming a surrogate mother?

What is your most important question or
concern about becoming a surrogate mother?