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Physician/Midwife
Become a Registered Physician/Request Detailed Program Information

Physician/Midwife Registration / Request for Detailed Program Information

Please fill out the form below and click submit.

For those physicians or midwives who have requested more information, once we have verified your credentials as a physician or midwife, we will contact you and provide you with detailed program information.

For those who have decided to become a registered physician, one of our staff physicians will contact you to provide you with your Physician Agreement for signature, answer any questions, order your patient education literature, and schedule your training class. The Physician Agreement is required to be completed before your membership is activated and your Insurance Assist ^SM benefits are available.

We are happy to answer any questions, so if you have any, please fill out the form, enter your questions at the bottom, and click submit. Thank you!

* Required fields
Name *
E-mail Address *
Reason for Submitting Form *
Practice Name *
Address *
Address 2
City *
State *
Zip Code *
County *
Telephone Number *
Fax Number *
Email Address *
Web Site Address (If applicable)
Number of Physicians in Practice *
Number of Office Locations in Practice *
Please list locations and addresses of each additional office location
Hospital Affiliations *
Approximate number of babies delivered each year by physicians in practice *
Current number of maternity patients per physician in practice *
How are you currently serving your patients' umbilical cord blood collection and banking needs? *
How did you hear about Stem Cell Authority Ltd.? *
If you have any questions, please enter them here *

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Stem Cell Authority Ltd.
123 S. Miller Road
Fairlawn, Ohio 44333

330-835-0200

Toll Free - 888-835-0288

Fax - 330-835-4878

Email: information@stemcellauthority.com