(d) If the abortion will be performed or induced surgically and she desires to exercise the rights under division (A) of section
3726.03 of the Revised Code, she has completed the disposition determination under section
3726.04 or
3726.041 of the Revised Code.
A form shall be completed for each zygote, blastocyte, embryo, or fetus to be aborted. If a pregnant woman is carrying more than one zygote, blastocyte, embryo, or fetus, she shall sign a form for each zygote, blastocyte, embryo, or fetus to be aborted.
The form shall contain the name and contact information of the physician who provided to the pregnant woman the information described in division (B)(1) of this section.