Placenta Donation Interest Form
Thank you for your interest in placenta donation! After submitting this form, a Lifeline of Ohio staff member will follow up to answer any questions you may have. If you then decide to sign up to donate your placenta, a staff member will complete the necessary paperwork over the phone.
Your Name
*
First Name
Last Name
I am....
*
Please Select
Interested in donating my placenta
An OBGYN office staff member
A hospital staff member
Enter the patient's information below.
Patient's Name
*
First Name
Last Name
Mother/Patient Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
When is the best time to call? (Check all that apply)
Morning
Afternoon
Evening
Would you like to add a secondary phone number?
Yes
No
Secondary Phone Number
Please enter a valid phone number.
Secondary Phone Number Type
Home Phone
Work Phone
Significant Other Phone
Other
Please select the delivery hospital
*
Please Select
Adena Regional Medical Center
Avita Health System - Galion Hospital
Avita Health System- Ontario Hospital
Fairfield Medical Center
Genesis Hospital
Holzer Medical Center- Gallipolis
Knox Community Hospital
Licking Memorial Hospital
Lima Memorial Hospital
Marietta Memorial Hospital
Memorial Hospital
Mount Carmel East
Mount Carmel Grove City
Mount Carmel St. Ann's
OhioHealth Berger Hospital
OhioHealth Mansfield Hospital
OhioHealth O'Bleness Hospital
OhioHealth Pickerington Methodist Hospital
OhioHealth Riverside Methodist Hospital
Southeastern Ohio Regional Medical Center
Southern Ohio Medical Center
St. Rita's Medical Center
The Ohio State University Wexner Medical Center
WVU Camden Clark Medical Center
Other
Please select your OBGYN office at Adena Regional Medical Center
*
Please Select
Adena OB/GYN- Blackwater
Adena OB/GYN- Hospital Campus
Other
Please select your OBGYN office at Avita Health System - Galion Hospital
*
Please Select
Avita OB/GYN- Ontario
Avita OB/GYN- Galion
Avita OB/GYN- Bucyrus
Other
Please select your OBGYN office at Avita Health System- Ontario Hospital
*
Please Select
Women's Care Inc.-Trimble Rd location
Avita Ontario- Women's Care Inc.- Avita Ontario location
Other
Please select your OBGYN office at Fairfield Medical Center
*
Please Select
Fairfield Medical Center - River Valley Women's Health- Dr. Delong
Fairfield Medical Center - OB/GYN Associates of Lancaster, Inc
Fairfield Medical Center - River Valley Women's Health- Dr. Jerig
Fairfield Medical Center - Fairfield Healthcare Professionals OBGYN
Other
Please select the OBGYN office at The Ohio State University Wexner Medical Center
*
Please Select
OSU - Avina Women's Care: Columbus
OSU - Professionals for Women's Health: Dublin
OSU - Professionals for Women's Health: Columus
OSU - Professionals for Women's Health: Westerville
OSU - Avina Women's Care: Bradenton
OSU OPCareUA
OSU - Ohio State Obstetrics and Gynecology Worthington
OSU - Ohio State McCampbell Outpatient Care
OSU Outpatient Care Gahanna
OSU - Ohio State Obstetrics and Gynecology Kenny Road
OSU - Ohio State Outpatient Care Upper Arlington
OSU - Womankind OBGYN- Gahanna
Other
Please select the OBGYN office at Genesis HealthCare System
*
Please Select
Genesis HealthCare System - PrimeCare of Southeastern Ohio: Aepli
Genesis HealthCare System - Dr. John Lepi
Genesis HealthCare System - PrimeCare of Southeastern Ohio: Wehrum, Hothem
Genesis HealthCare System - Muskingum Valley Health Center- Goodarzi
Genesis Healthcare System OB/GYN
Genesis HealthCare System - Dr. Jeffrey Downing: Physician Pavilion 945
Other
Please select the OBGYN office at Holzer Medical Center-Gallipolis
*
Please Select
Holzer OBGYN
Other
Please select the OBGYN office at Mount Carmel East
*
Please Select
Mount Carmel East - Columbus OBGYN New Albany
Mount Carmel East - Columbus OBGYN Pickerington
Mount Carmel East - Columbus OBGYN Columbus- Taylor Station
Mount Carmel East - Columbus Metropolitan OBGYN- Gahanna
Mount Carmel East - Columbus Metropolitan OBGYN- Columbus
Mount Carmel East - Columbus Metropolitan OBGYN- Pickerington
Mount Carmel East - Her Health OBGYN- Easton
Mount Carmel East - Her Health OBGYN- Pataksala Medical Center
Mount Carmel East - Columbus Women's Care Inc
Mount Carmel East - Maternal Fetal Medicine- MCE
Mount Carmel East - Womankind OBGYN- Pickerington
Mount Carmel East - Womankind OBGYN- Canal Winchester
Other
Please select the OBGYN office at St. Rita's
*
Please Select
St. Rita's - Women's Health for Life: St. Rita's
St. Rita's - Women's Health for Life: Lima Memorial
St. Rita's - OB/GYN Specialists of Lima
Other
Please select the OBGYN office at Knox Community Hospital
*
Please Select
Knox Medical: Department of Specialty Care
Other
Please select the OBGYN office at Southeastern Ohio Regional Medical Center
*
Please Select
SORMC - Muskingum Valley Health Center- OBGYN Specialists of SE Ohio
Other
Please select the OBGYN office at Southern Ohio Medical Center
*
Please Select
SOMC OB/GYN Associates- Haldarman Building
SOMC OB/GYN Associates- Waller Building
SOMC - Dr. Jennifer Roberts
Other
Please select the OBGYN office at Memorial Hospital
*
Please Select
Memorial - Avina Women's Care Marysville
Other
Please select the OBGYN office at Mount Carmel Grove City
*
Please Select
Mount Carmel Grove City - Mount Carmel Medical Group OBGYN
Mount Carmel Grove City - Maternal Fetal Medicine- MCGC
Mount Carmel Grove City OB Clinic
Other
Please select the OBGYN office at Mount Carmel St. Ann's
*
Please Select
Mount Carmel St. Ann's - Columbus Metropolitan OBGYN- Gahanna
Mount Carmel St. Ann's - Columbus Metropolitan OBGYN- Columbus
Mount Carmel St. Ann's - Columbus Metropolitan OBGYN- Pickerington
Mount Carmel St. Ann's - Her Health OBGYN- Easton
Mount Carmel St. Ann's - Her Health OBGYN- Pataksala Medical Center
Mount Carmel St. Ann's - Columbus Women's Care Inc
Mount Carmel St. Ann's - Associates in Central Ohio OBGYN- Westerville
Mount Carmel St. Ann's - Associates in Central Ohio OBGYN- East Columbus
Mount Carmel St. Ann's - Associates in Central Ohio OBGYN-Dublin
Mount Carmel St. Ann's - Eastwind Women's Health- Westerville
Mount Carmel St. Ann's - Eastwind Women's Health- Granville
Mount Carmel St. Ann's - Professionals for Women's Health: Columbus
Mount Carmel St. Ann's - Professionals for Women's Health: Westerville
Mount Carmel St. Ann's - Professionals for Women's Health: Dublin
Mount Carmel St. Ann's - Crosswood's Women's Health
Mount Carmel St. Ann's- Northside Women's Health
Mount Carmel St. Ann's - Westar OB-GYN: Westerville
Mount Carmel St. Ann's - Westar OB-GYN: Sunbury
Mount Carmel St. Ann's - Maternal Fetal Medicine- St Ann's
Mount Carmel St. Ann's - Women's Integrative Medicine OB/GYN
Other
Please select the OBGYN office at Licking Memorial Hospital
*
Please Select
Licking Memorial Women's Health- Pataskala
Licking Memorial Women's Health- Newark
Licking Memorial Women's Health- Downtown Newark
Licking Memorial Women's Health- Granville
Other
Please select the OBGYN office at Lima Memorial Hospital
*
Please Select
Lima Memorial Alliance OB/GYN
Lima - Women's Health for Life: St. Rita's
Lima - Women's Health for Life: Lima Memorial
Other
Please select the OBGYN office at Marietta Memorial Hospital
*
Please Select
Marietta- Dr. Stanley
Marietta Gynecological Associates
Other
Please select the OBGYN office at OhioHealth Riverside Methodist Hospital
*
Please Select
Associates of Central Ohio OBGYN- Dublin
Associates of Central Ohio OBGYN- East Columbus
Associates of Central Ohio OBGYN- Westerville
Avina Women's Care- Columbus (Olentangy River Rd)
Avina Women's Care- Dublin Bradenton Rd.
Avina Women's Care- Dublin Methodist Hospital
Avina Women's Care- Powell
Avina Women's Care- UA Lane Ave
Avina Women's Care- UA Chatham Rd
Avina Women's Care- Westerville Executive Campus Drive
Avina Women's Care- Westerville Polaris Parkway
Crosswoods Women's Health
Eastwind Women's Health- Granville
Eastwind Women's Health- Westerville
Northwest OBGYN
Professionals for Women's Health- Dublin
Professionals for Women's Health- Westerville
Riverside Community Care OBGYN
Women's Physicians in OB/GYN- Dublin
Women's Physicians in OB/GYN- Riverside Methodist Hospital
Other
Please select the OBGYN office at WVU Camden Clark Medical Center
*
Please Select
WVU Camden Clark OBGYN- Dr. Casalenuovo
WVU Camden Clark OBGYN- Dr. Irvin
WVU Camden Clark OBGYN- Dr. Lowden
WVU Camden Clark OBGYN Marietta- Dr. Galupo, Dr. White
WVU Camden Clark OBGYN- Dr. Shockley
Dr. Peter Filozof OBGYN
Other
Please select the OBGYN office at OhioHealth Berger Hospital
*
Please Select
OhioHealth Physician Group OBGYN Berger
Other
Please select the OBGYN office at OhioHealth O'Bleness Hospital
*
Please Select
OhioHealth Physicians Group OBGYN- Athens
Other
Please select the OBGYN office at OhioHealth Mansfield Hospital
*
Please Select
Cornerstone OBGYN
OhioHealth Physician Group OBGYN Mansfield
University Hospital Samaritan Women's Care
Womens Care Inc. - Trimble Rd
Other
Please select the OBGYN office at OhioHealth Pickerington Methodist Hospital
*
Please Select
Columbus OBGYN New Albany
Columbus OBGYN Pickerington
Columbus OBGYN Columbus- Taylor Station
Columbus Metropolitan OBGYN- Gahanna
Columbus Metropolitan OBGYN- Pickerington
Columbus Women's Care
OBGYN Associates of Lancaster
OhioHealth Physician's Group Reynoldsburg
Other
Please select the OBGYN office [USE FOR DUPLICATING]
*
Please Select
Adena OB/GYN- Blackwater
Adena OB/GYN- Hospital Campus
Avita OB/GYN- Ontario
Avita OB/GYN- Galion
Avita OB/GYN- Bucyrus
Fairfield Medical Center - River Valley Women's Health- Dr. Delong
Fairfield Medical Center - OB/GYN Associates of Lancaster, Inc
Fairfield Medical Center - River Valley Women's Health- Dr. Jerig
Fairfield Medical Center - Fairfield Healthcare Professionals OBGYN
Genesis - PrimeCare of Southeastern Ohio: Aepli
Genesis - Dr. John Lepi
Genesis - PrimeCare of Southeastern Ohio: Wehrum, Hothem
Genesis - Muskingum Valley Health Center- Goodarzi
Genesis Healthcare System OB/GYN
Genesis - Dr. Jeffrey Downing: Physician Pavilion 945
Knox Medical: Department of Specialty Care
Licking Memorial Women's Health- Pataskala
Licking Memorial Women's Health- Newark
Licking Memorial Women's Health- Downtown Newark
Lima Memorial Alliance OB/GYN
Lima - Women's Health for Life: St. Rita's
Lima - Women's Health for Life: Lima Memorial
Marietta- Dr. Stanley
Marietta Gynecological Associates
Memorial - Avina Women's Care Marysville
Mount Carmel East - Columbus OBGYN New Albany
Mount Carmel East - Columbus OBGYN Pickerington
Mount Carmel East - Columbus OBGYN Columbus- Taylor Station
Mount Carmel East - Columbus Metropolitan OBGYN- Gahanna
Mount Carmel East - Columbus Metropolitan OBGYN- Columbus
Mount Carmel East - Columbus Metropolitan OBGYN- Pickerington
Mount Carmel East - Her Health OBGYN- Easton
Mount Carmel East - Her Health OBGYN- Pataksala Medical Center
Mount Carmel East - Columbus Women's Care Inc
Mount Carmel East - Maternal Fetal Medicine- MCE
Mount Carmel East - Womankind OBGYN- Pickerington
Mount Carmel East - Womankind OBGYN- Canal Winchester
Mount Carmel Grove City - Mount Carmel Medical Group OBGYN
Mount Carmel Grove City - Maternal Fetal Medicine- MCGC
Mount Carmel Grove City OB Clinic
Mount Carmel St. Ann's - Columbus Metropolitan OBGYN- Gahanna
Mount Carmel St. Ann's - Columbus Metropolitan OBGYN- Columbus
Mount Carmel St. Ann's - Columbus Metropolitan OBGYN- Pickerington
Mount Carmel St. Ann's - Her Health OBGYN- Easton
Mount Carmel St. Ann's - Her Health OBGYN- Pataksala Medical Center
Mount Carmel St. Ann's - Columbus Women's Care Inc
Mount Carmel St. Ann's - Associates in Central Ohio OBGYN- Westerville
Mount Carmel St. Ann's - Associates in Central Ohio OBGYN- East Columbus
Mount Carmel St. Ann's - Associates in Central Ohio OBGYN-Dublin
Mount Carmel St. Ann's - Eastwind Women's Health- Westerville
Mount Carmel St. Ann's - Eastwind Women's Health- Granville
Mount Carmel St. Ann's - Professionals for Women's Health: Columbus
Mount Carmel St. Ann's - Professionals for Women's Health: Westerville
Mount Carmel St. Ann's - Professionals for Women's Health: Dublin
Mount Carmel St. Ann's - Crosswood's Women's Health
Mount Carmel St. Ann's - Westar OB-GYN: Westerville
Mount Carmel St. Ann's - Westar OB-GYN: Sunbury
Mount Carmel St. Ann's - Maternal Fetal Medicine- St Ann's
SORMC - Muskingum Valley Health Center- OBGYN Specialists of SE Ohio
SOMC OB/GYN Associates- Haldarman Building
SOMC OB/GYN Associates- Waller Building
SOMC - Dr. Jennifer Roberts
St. Rita's - Women's Health for Life: St. Rita's
St. Rita's - Women's Health for Life: Lima Memorial
St. Rita's - OB/GYN Specialists of Lima
OSU - Avina Women's Care: Columbus
OSU - Professionals for Women's Health: Dublin
OSU - Professionals for Women's Health: Columus
OSU - Professionals for Women's Health: Westerville
OSU - Avina Women's Care: Bradenton
OSU OPCareUA
OSU - Ohio State Obstetrics and Gynecology Worthington
OSU - Ohio State McCampbell Outpatient Care
OSU Outpatient Care Gahanna
OSU - Ohio State Obstetrics and Gynecology Kenny Road
OSU - Ohio State Outpatient Care Upper Arlington
OSU - Womankind OBGYN- Gahanna
Other
If "Other," what is the delivery hospital?
*
If "Other," what is the OBGYN office?
*
Has a c-section been scheduled?
Yes
No
Please enter date and time of scheduled c-section
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
How did you learn about the placenta donation program?
Brochure or flyer from my OBGYN office
Mentioned to me at my OBGYN office
Friend or family social media post
Lifeline of Ohio social media post
Online search
Word of mouth
Other
Please feel free to share any additional questions or comments, or any special circumstances regarding the pregnancy (surrogacy, IVF, twins, etc.) we should be aware of.
Submit
Should be Empty: