Request Support

All Information Is Confidential!

The following form must be filled out in order to receive email or phone support. If you do not have email access, please call us toll free number at (888) 447-4754. Sidelines does offer international support by email only.

We do ask sensitive and personal information such as ethnicity and medical background. Please be assured that all information collected is completely confidential. Our questions are designed to follow Center For Disease Control (CDC) guidelines so that we are able to merge our confidential data with theirs. New data suggests that some medical conditions are more prevalent in certain age groups, races, and geographical locations. We are in the unique position to be able to provide the medical community with information that could improve the scope and effectiveness of prenatal care, diagnostic and treatment options.

As well as providing important medical data, the information you provide allows us to match you as closely as possible with a volunteer. Due to the high demand for online and phone support, Sidelines can only offer personal support to those who are currently pregnant or in need of NICU support. We can match you with a trained Sidelines volunteer who has previously experienced a similar pregnancy complication. Depending on which you choose, your volunteer will support you throughout the remainder of your pregnancy and / or NICU experience through email messages or by calling you on the phone.

Please note: Sidelines does not give medical advice. If you want more specific information on your treatment plan, have questions about the medications you are taking, or think you might be in pre-term labor, please call your medical professional, case manager, or local hospital.

If you would prefer for someone to contact you by phone instead of filling out this form online, or you need immediate assistance, please call us at (888) 447-4754.

Please note that Sidelines will make every effort to contact you via the email address you provide us. If you are a Yahoo, Hotmail, or GMail user, please be sure to check your email junk folders in case our reply gets misdirected. If this happens to you, please set the security level to allow email from Sidelines or call (888) 447-4754 with any questions.

Request Support

First Name(*)
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Last Name(*)
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Age(*)
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Occupation(*)
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Email Address(*)
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Partner's Name(*)
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Street Address(*)
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City(*)
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State (Or Province if outside the United States)(*)
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Zip Code(*)
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Country(*)
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Phone Number(*)
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Hospital Phone Number (If Currently Hospitalized)
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Extension
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Name of Medical Insurance Company(*)
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Physician's Name(*)
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Name of hospital where you will deliver(*)
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City(*)
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State or Province(*)
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How did you find out about Sidelines?(*)
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If other please specify
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Type of support requested(*)
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Due Date(*)
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Number of weeks along in current pregnancy(*)
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Pregnancy number
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If more than 4th provide number
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Do you have children?(*)
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If yes please provide their ages
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Optional What is your ethnic background?
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Pregnancy Complications (Check all that apply to your pregnancy)
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Was this pregnancy the result of infertility management?(*)
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Fertility Treatments (Check all that apply)
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Types of Treatments You Are Receiving
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Medications (Check all that apply to your current pregnancy)
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What other information would you like to add about your pregnancy?
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If you could choose ONE primary pregnancy complication for support, it would be...(*)
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As part of our efforts to improve the value and quality of our services, we contact patients at the end of their pregnancy to collect information about the support received. May we contact you for a brief interview?(*)
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Are you interested in helping other moms experiencing a high risk or complicated pregnancy? Check here if you would like to receive information on becoming a Sidelines volunteer after you deliver.(*)
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