Gestational Carrier Initial Inquiry

1Personal Information
2Pre-Screening Questions

If you have already created an account, please login: https://reproductiveassist.o-jms.com/user/login

First Name

Last Name:

Middle Name

Maiden Name (if applicable)

Are you a US Citizen or permanent resident?

Both you and your partner, if applicable, will be subject to a background check. Will you both pass the background check?

Primary Phone Number for contacting you:

What type of phone number is this?

May we leave a voicemail at this number?

Your email address:

How do you prefer to be contacted?

Phone Call

Text

What is the best time to reach you?

Morning

Afternoon

Evening

What is your height? *We aren't being intrusive here; fertility clinics specify an acceptable range for Body Mass Index (BMI) based on height and weight.

What is your current weight (lbs)?

lbs

Date of Birth:

Sun Mon Tue Wed Thu Fri Sat

Street Address, line 1:

Street Address, line 2:

City:

Country:

State:

Zip Code:

In consideration of using limited marketing resources, please let us know how you found this application?

Have you had at least one previous successful pregnancy and birth?

Have you ever been a gestational carrier before?

How many live births have you had?

How many C-sections have you had?

Are you currently breastfeeding?

Are you willing to administer self-injectable medications (we will give you training)?

Do you live in Louisiana?

Are you currently receiving any local, state or federal aid including food stamps?

Have you or anyone who lives in your home been convicted of a felony?

Upon clicking the Submit button, assuming the pre-screening criteria is met, you will be taken to the User Portal to continue your application in our secure portal.

An email will be sent to you with information on how to log back in to the User Portal in the future. Be sure to check your Junk/Spam folder for this information.

Please log back on to the system and complete the rest of your application in a day or two. Remember to SAVE after each section. Once your application is complete, we will review it and email you to set up the phone screening.

If you have any questions, you can call 513.831.9207 or email [email protected] We look forward to seeing your completed application and having you as a surrogate.