FAMILY BANKING ENROLLMENT FORM

Transcription

1 8785 SW 165 th Avenue, Suite 101 Miami, Florida GENECELL (93632) FAMILY BANKING ENROLLMENT FORM We appreciate you choosing GeneCell International, LLC. for your private cord blood and cord tissue storage needs. Please take a few minutes review and complete the attached forms required for private family cord blood and cord tissue storage. FORMS INCLUDED IN AGREEMENT Section 1 Terms and Conditions Section 2 Informed Consent Section 3 Medical and Health History Profile Section 4 Next of Kin Information and Reference Info Section 5 Storage Options Section 6 Payment Processing Form Page 1 of 12

2 SECTION 1 TERMS AND CONDITIONS This is an agreement between GeneCell International, LLC. (GCI), and the expectant parent (s) ( Clients ), who wishes GCI to provide processing, freezing, cryogenic storage and related services for the cells collected from their baby s umbilical cord, if applicable, cord segment and placenta (Cord Blood), following delivery. GENECELL INTERNATIONAL (GCI) & CLIENT RESPONSABILITIES GCI is responsible for providing a complete cord blood collection kit (not returnable/non-refundable) for you to bring to the hospital and for sending training materials to the medical professional expected to perform the collection. After collection of the cord blood unit, cord tissue if applicable, and maternal blood sample, Client will arrange for the courier to transport the unit to GCI s processing laboratory using GCI s preferred method of transportation, our local courier or Federal Express Priority. If any complication occurs during birth your physician/midwife may elect not to collect the cord blood and/or cord tissue. GCI will process, cryopreserve and store the cord blood unit, if applicable, cord tissue at its laboratory and cryogenic storage facility. GCI will send you written test results from the cord blood, and if applicable, cord tissue units. Client agrees to give GCI authorization to test maternal blood, cord blood samples and/or cord tissue samples and also agrees to the release of these test results to you and your physician/midwife if certain test results show any abnormalities. GCI may choose not to process and/or store the cord blood and/or cord tissue units if it does not meet certain requirements including, but not limited to: low volume, low cell counts, the cord blood and/or cord tissue is not collected properly, not handled or shipped according to GCI procedures, or if the unit tests positive for certain microbial contamination. GCI will notify the client regarding the disposition of the units. All information and test results obtained by GCI may be used where confidentiality is maintained as required by federal or state law. Client is responsible for reading, completing and signing the enrollment forms and returning them to GCI prior to delivery, as well as payment of all fees. Client agrees to inform their physician/midwife of their desire to collect their child s cord blood and if applicable, cord tissue. In the event that the cord blood unit and cord tissue is needed for transplant, GCI may conduct appropriate testing on the cord blood, cord tissue and maternal blood samples and ship the cord blood stem cells together with the cord tissue stem cells, if applicable, to the appropriate facility upon written request from a physician qualified to perform a stem cell transplant, Client is responsible for all expenses. GCI may assist on fees obstetrician practices may charge for the collection of cord blood and cord tissue. Please check with your obstetrician practices for details. Client is responsible for notifying GCI of changes to Client s contact and payment information while this agreement is in effect. GENERAL The legal guardian may cancel this agreement at any time while the child is still a minor. At the age of 18 years old, your child has ownership claims to the cord blood unit, if applicable cord tissue and only he or she may cancel this agreement. If at any time you elect to terminate this agreement, you must notify GCI in writing. GCI may terminate this agreement upon written notice to you if for any reason you fail to pay any required fees within thirty (30) days of the payment due date. GCI will retain all rights to the cord blood unit and cord tissue and neither you nor GCI will have any continuing obligations to the other. Any changes to this agreement must be in writing and agreed upon by ALL parties in order to be enforceable. This agreement will be governed by and construed in accordance with the laws of the State of Florida, without giving effect to conflict of laws, rules or principles. This agreement has been prepared in the English language and the English language shall control its interpretation. SECTION 2 INFORMED CONSENT Informed Consent for Private Storage of Umbilical Cord Blood and Cord Tissue with GeneCell International BACKGROUND Before the birth of your child, the baby s blood cells move through his/her body, umbilical cord, and placenta. Some of these cells carry oxygen and nutrition from the mother s body to the baby. After the birth of the baby, the umbilical cord is clamped, cut, and separated from the baby. Page 2 of 12

3 The umbilical cord blood is rich in stem cells, which are currently being used to replace the blood-forming cells in persons with certain diseases. This replacement process is called a transplant. These transplants are referred to as cord blood transplants. When collecting your baby s cord blood, you also have an opportunity to collect a segment of the umbilical cord referred as cord tissue. Umbilical cord tissue is a gelatinous substance, which functions as the primary connective tissue of the umbilical cord and is referred to as Wharton s Jelly which is rich in adult stem cells. These cells have an excellent potential for tissue engineering, gene therapy applications and regenerative medicine. These cells are an excellent candidate for regenerative medicine and tissue engineering applications. If you enroll in the GeneCell International umbilical cord blood and cord tissue banking program, your physician will deliver the baby in the normal manner. After the umbilical cord has been clamped, your physician may decide to collect the umbilical cord blood while waiting for the placenta to be delivered (ideal collection situation) or he/she may wait until after you have delivered the placenta to collect the cord blood. In either case, a vein in the umbilical cord will be perforated with a small needle, attached to a sterile umbilical cord blood collection bag and the blood from the umbilical cord will be withdrawn. Once all of the cord blood has been withdrawn the cord tissue collection process begins. Your physician will cut approximately a 3 inch segment of the umbilical cord using sterile scalpels or scissors. This piece of cord is to be inserted into a sterile collection bottle provided within the cord blood collection kit. The bottle is to be tightly re-capped, placed back into the GeneCell collection kit, then packaged and transported to our laboratory along with the cord blood and maternal blood vials. The umbilical cord blood and cord tissue will be processed, tested, frozen and stored until it is needed for transplant. PURPOSE Stem cells found in a baby s umbilical cord blood can be used to replace the bone marrow of a patient in need or treat different metabolic disorders and the cord tissue for regenerative medicine. The GeneCell International umbilical cord blood and cord tissue banking program has been designed to collect the umbilical cord blood and cord tissue stem cells, process and cryogenically preserve them for your child, or other first degree relative, for use in transplantation. You are being asked to privately store your baby s umbilical cord blood and if applicable, cord tissue with GeneCell International. If you decide to enroll in the GeneCell International umbilical cord blood and cord tissue banking program, you will be agreeing to store your baby s umbilical cord blood and cord tissue in a private bank at GeneCell International s facility located in Miami, FL. AGREEMENT By deciding to cryogenically preserve your child s umbilical cord blood and/or cord tissue with GeneCell International, you are agreeing to the following: 1. You will allow the blood and, if applicable, a segment from your child s umbilical cord to be collected after the delivery of your baby and sent to the GeneCell International Laboratory for processing, testing and cryogenic storage. The umbilical cord blood unit and cord tissue will be stored at our facility until requested for by you and your physician, or by the child it was taken from and his/her physician, if the child is 18 years of age or older. We reserve the right to discard your child s umbilical cord blood unit and, if applicable, the cord tissue due to lack of payment. In this instance, we will make every effort possible to contact you to inform you of the decision to discard the unit prior to taking such action. 2. If your child s umbilical cord blood unit and cord tissue does not meet certain minimum criteria set forth by GeneCell International (there is no guarantee that it will meet the minimum criteria), you will be notified of this fact via letter, in which we will explain the situation and alternatives to you, and you will be given a choice to have us continue with the storage of the unit or to discard it with no cost to you or your family, other than the non-refundable fees. There are several factors that may contribute to the umbilical cord blood unit and/or cord tissue not meeting the minimum criteria and they include but are not limited to: a. Amount of umbilical cord blood collected b. Placental weight Page 3 of 12

4 c. Birth weight of the baby d. Delivery method (vaginal or caesarian section) e. Time of transport f. Amount or size of cord tissue collected 3. You will provide us a sample of your systemic blood (maternal blood) to be tested for infectious disease including but not limited to Hepatitis, Syphilis, HIV, HTLV, Cytomegalovirus, West Nile Virus and Chagas disease. a. Except as outlined below, all test results are confidential. Any tests performed will be done to ensure the safety of the individual who may receive the umbilical cord blood and, if applicable, the cord tissue for transplant purposes. We will inform you of any positive test results that may have an adverse impact on your or your baby s health. Additionally, some laws require GeneCell to provide the names of persons who test positive for certain diseases, i.e. HIV, to public or state health agencies. These agencies may contact you if you have positive test results. 4. You will be asked to answer questions regarding you and your family s medial history on the medical history questionnaire. You will be asked for information about your pregnancy, medications you are taking and any medical problems that you, your family, the baby s father, or the baby s father s family may have had. There are also questions about your current and past lifestyle, including sexual history and drug use. If you decline to answer, your baby s cord blood and/or cord tissue will not be stored. 5. You will allow you and your baby s medical charts to be reviewed by GeneCell International representatives, specifically for pregnancy and delivery information and hospital test results up to the time of your discharge from the hospital if applicable. 6. You will allow us to contact you to ask you about any changes in your baby s health which may affect the umbilical cord blood and cord tissue unit s suitability for transplantation. 7. Umbilical cord blood has been shown to be an effective treatment option for over 80 diseases mainly involving; cancer, bone marrow failure syndromes, blood disorders/hemoglobinopathies, and metabolic disorders. However, the statistical probability that your child will require the umbilical cord blood unit in order to treat these conditions is small. 8. Stem cells that are collected from the child s cord tissue may assist in the treatment of future disease that the child may suffer, but such assistance or suitability cannot be guaranteed. 9. There are certain diseases that your child s own cord blood or cord tissue will not be able to treat; in this case a HLAmatched unit from another individual may be required for transplantation. 10. There are no guarantees that the use of your child s umbilical cord blood unit or cord tissue will result in a successful transplantation. There are limitations to a successful transplant and they include but are not limited to the disease treated and the size of the recipient. In addition, your child s umbilical cord blood units and cord tissue can be used for first-degree relatives (if there is a HLA match) only. No third party can use the umbilical cord blood units or cord tissue for transplantation. I/We, the Parent(s)/Legal Guardian(s), on behalf of myself/ourselves and my/our/ unborn child ( Child ), hereby grant permission to GeneCell International, ( GCI ) to process, test, and store Umbilical and/or Placental Cord Blood ( Cord Blood ) and the cord tissue after delivery of my/our/the Child. This document constitutes a legally binding Agreement between GCI and the undersigned Parent(s) or Legal Guardian(s), the ( Client ). This Agreement outlines the rights and obligations of the parties as set forth in this document. I/We, the undersigned Client, agree and acknowledge understanding of the following: 1) The term Cord Blood also indicates the Stem Cells in the Umbilical Cord Blood that are extracted, processed, cryopreserved, and stored for future use. Page 4 of 12

5 2) The term Cord Tissue indicates a segment (or piece) of the umbilical cord itself. 3) The Client understands that the Client is the custodian of the Cord Blood and Cord Tissue until the Child reaches (18) years of age. At that time, GCI shall recognize any claims made by the Child for the Cord Blood and Cord Tissue. 4) The Client understands Cord Blood stem cell transplantation is relatively new and may offer possible future benefits to the Child and other potential beneficiaries in treating diseases such as leukemia, certain cancers, genetic and metabolic disorders. The Client understands that Cord Blood and Cord Tissue offers a source of stem cells, and the Client acknowledges that they have been informed of alternative sources of stem cells such as bone marrow and peripheral blood. The Client understands that cryopreservation of Cord Blood and Cord Tissue is a relatively new procedure and some laboratory tests and studies thus far have indicated it is a successful method of preservation of Cord Blood and Cord Tissue; however, no assurance or guarantee can be made about the effectiveness of preservation nor the benefits or utility derived there from. The Client also understands the Child or another family member may never need to use the Cord Blood Unit and Cord Tissue and the Cord Blood Unit and Cord Tissue may not be a suitable genetic match for the related family member. 5) We advise the Client to discuss stem cell storage with a qualified medical professional, such as your Obstetrician- Gynecologist and/or your family physician and/or your Oncologist. This discussion should include the potential benefits of collection, preservation and possible future use of Cord Blood and Cord Tissue stem cells, and the current diseases stem cell transplants may have benefited. This discussion should also include the possible risks and benefits. GCI is in no way providing medical advice, care or treatment to you. 6) Your baby s delivery and that of the placenta should occur in the usual manner as if no cord blood or Cord Tissue collections were taking place. There will be no increased risk to you or your baby by participating in the GeneCell International Umbilical Cord Blood Banking and Cord Tissue Program. There is no change in the actual delivery process and your doctor can cancel the cord blood and Cord Tissue collection at any time if he/she thinks it might pose a potential harm to you or the baby. The sample of blood from your arm will likely cause minor discomfort at the site where the blood is taken. For example, some bleeding and a small bruise may occur. Infection is rare, but could occur. If you are uncomfortable at the sight of blood, you may feel light-headed or faint. All normal precautions will be taken to keep these side effects from happening. 7) The umbilical cord blood taken from your child is an exact HLA (genetic) match for that child. There is a 25% chance that it will be an identical HLA match for any of that child s siblings. 8) The Client understands that he/she must request a qualified Provider to collect the Cord Blood and Cord Tissue using the collection kit provided by GCI. In the event the Client-Indicated Provider is unfamiliar with the procedure, GCI will make a reasonable attempt to supply the Client-Indicated Provider with educational materials. The Client acknowledges that the Cord Blood and Cord Tissue will be sent to an independent laboratory ("Laboratory") for testing during the term of this contract. GCI s duties are limited to providing educational materials and the collection kit, and GCI is not responsible for any medical procedure or advice. 9) The Client understands that there are risks with any medical procedure, that there may be additional considerations or unforeseeable circumstances during the period of delivery and that the safety and care of the baby and mother are of primary concern. Therefore, in the event the Cord Blood and Cord Tissue cannot be collected, Client releases from liability and waives all claims against the Provider, Hospital, Hospital Staff, GCI, its shareholders, directors, officers, owners, employees, representatives, agents, affiliates and consultants, and the Client enters into this agreement with this understanding. 10) The Client understands that Cord Blood and Cord Tissue is normally discarded after delivery, appropriated for medical research or stored in a public banking facility and that the decision to collect, process, and store the child s Cord Blood and Cord Tissue is a voluntary act on the part of the Client that may allow them to protect their personal rights to the Cord Blood and Cord Tissue. 11) The Client understands there is a risk of contamination when collecting Cord Blood and Cord Tissue; therefore the Cord Blood and Cord Tissue will be tested for fungus and bacteria by GCI s contracted laboratory. If the Cord Blood and/or Cord Tissue are deemed unsuitable for storage, the Client will not incur a cancellation fee. Page 5 of 12

6 12) The Client agrees to be responsible for delivery of the Child s Cord Blood and Cord Tissue to the Laboratory within 72 hours of collection. Upon request of Client, GCI may, at its sole discretion, facilitate the delivery of the Cord Blood and Cord Tissue on the Client s behalf. 13) The Client understands Cord Blood and Cord Tissue collection is voluntary and that the Client has the right to stop the collection at any time. In the event the decision to stop the Cord Blood collection is made prior to collecting the Cord Blood, GCI will close the clients account and no further fees are due to GCI. 14) Financial Obligation - You will be charged collection, processing and storage fees. If we find the umbilical cord blood unit to be unsuitable for transplant, we will contact you, and you will then have the option to discard the umbilical cord blood unit at no cost to you or your family (except for non-refundable fees). 15) Fees - (See Attached Storage Options) Client agrees to pay GCI the fees set forth on the Payment Options attached hereto. 16) Term - The Client understands the initial term of this Agreement shall commence on the date the client sends to the Laboratory the Cord Blood and Cord Tissue ("Storage Date") and shall continue for a one (1) year period thereafter, unless client has chosen to elect a multiple year storage option. This contract will automatically renew at the end of each one (1) year period, unless either party provides written notice to the other of its intent not to renew at least sixty (60) days prior to the anniversary date of the Storage Date. 17) Termination and Release - This Agreement shall terminate upon the occurrence of any one of the following: A. With Cancellation Penalty i. Failure of the Client to pay the annual storage fee on the specified due date. Upon termination, the Client releases all rights and waives all claims to the stored Cord Blood and Cord Tissue and its disposition is at GCI s sole discretion. Client agrees to pay a cancellation fee of $60.00 for appropriate disposal of stored Cord Blood and Cord Tissue. ii. Prior to renewal of agreement, Client delivers a sixty (60) day written notice to GCI terminating this Agreement. Upon termination of this Agreement by Client, Client shall pay to GCI a cancellation fee of $60.00 for appropriate disposal of stored Cord Blood and Cord Tissue. B. Without Cancellation Penalty i. GCI delivers thirty (30) days written notice to the Client terminating this Agreement. GCI will attempt to assign, offer options, or make arrangements for the continued storage of the Cord Blood and, if applicable, Cord Tissue. ii. Client determines they do not want to proceed with the collection process prior to collection. Kit is not returnable and initial fee of $ is non-refundable on Cord Blood Services and $ on Cord Tissue Services. Client will not be responsible for any fees thereafter. C. Upon termination of this Contract, Client agrees to release all rights and waive all claims against GCI, and its shareholders, directors, officers, owners, employees, agents, affiliates, representatives and consultants with regard to this Contract, the services hereunder and the Cord Blood and Cord Tissue, and agrees that GCI shall have no further liability to the Client or with regard to the Cord Blood and Cord Tissue after termination. 18) No Warranty or Guarantee; Limitation of Liability - The Client acknowledges that neither GCI nor any of its officers, directors, shareholders, executives, employees, agents, or consultants have made any representations, guarantees or warranties, express or implied, to the Client of any kind or nature, including, without limiting the generality of the foregoing, nor have there been any representations, warranties or guarantees with respect to (i) suitability of Cord Blood and Cord Tissue for the future treatment of diseases; (ii) successful treatment of diseases through Cord Blood and Cord Tissue transplantation; (iii) advantages of Cord Blood and Cord Tissue transplantation over other types of treatment using stem cells; (iv) the merchantability or fitness for a particular purpose or use of any product or service hereunder; (v) client agrees that should he or she make any claim against GCI, such claim shall be limited in total to the amount of Fees paid by the Client to GCI under this Contract; (vi) client acknowledges that results of test performed by the independent laboratory are not guaranteed. The elimination of some errors is not possible due to the nature of the tests. The independent laboratory does Page 6 of 12

7 not guarantee or warrantee the services. The Independent laboratory is not responsible for any losses or damages arising out of the services provided, unless and only to the extent caused by the independent laboratory s negligence or misconduct. 19) Collecting and Storing Your Child s Umbilical Cord Blood and Cord Tissue - There is no guarantee that your child s umbilical cord blood and Cord Tissue will be successfully collected or stored. Reasons that this may happen include but are not limited to: blood may not be collected due to complications at the time of birth, the amount of blood collected may be insufficient for processing, and the umbilical cord blood and Cord Tissue may contain a contaminant that would preclude it from being stored. In addition, there is always the possibility that another unexpected problem may arise and result in the umbilical cord blood and Cord Tissue not being collected and stored. 20) Withdraw (Preparation, Transfer, and Shipment) In the event that these cells are needed for treatment, the Client shall provide written notification to GCI. The notice shall include the name and address of the transplant physician and hospital receiving the Cord Blood and Cord Tissue. The decision of how many stem cells quantity are required will be made by the Client s transplant physician. The Client shall bear all costs related to the preparation and shipment of the Cord Blood and Cord Tissue. 21) Indemnify and Hold Harmless - The Client agrees to indemnify, defend and hold harmless GCI, the Processing Laboratory, and any of its agents, affiliates, shareholders, directors, officers, owners, employees, consultants and other representatives from and against any and all liability, loss, expense, attorney s fees, or claims from injury or damages, arising out of the services provided under this agreement. The Client further acknowledges that GCI is not responsible for the actions of others including but not limited to the Client s Physician or provider, the Hospital or its staff, Laboratory staff, and transporters of the Cord Blood and Cord Tissue. 22) Assignment - This Agreement is assignable by GCI to any individual, association, partnership, or other corporation, which is either providing a similar service or intends subsequent to such assignment to provide similar service. This agreement is not assignable by the Client without the written notification to and written consent by GCI. 23) Miscellaneous - This Agreement represents the entire Agreement between the parties concerning the subject matter hereof and there are no understandings, agreements, representations other than as herein set forth. This Agreement shall be binding upon the parties and their respective heirs, spouses, executors, administrators, agents, representatives, successors, and assigns. The Agreement shall be construed in accordance with the laws of the State of Florida, and any dispute or controversy hereunder shall be resolved in the local courts sitting in Florida. If any provision of this Agreement is deemed unenforceable, the remaining provisions hereof shall nevertheless be fully enforceable in accordance with their terms. 24) Change in Fees - Any fees set forth in this Contract, including the Storage Option form, is subject to changes or adjustment such as those that may reflect industry standards and governmental regulations. GCI will provide Client with written notice of any change in fees at least thirty (30) days prior to the date the payment is due. The annual fee stated in the Storage Option Form is fixed for a period of 5, 10 and 20 years, while under this agreement. 25) Client Consent to Release of Information - Client hereby agrees to the release of any and all information with regard to the Client, or the Child, or anything related to the services performed hereunder, to the hospital, laboratory, and any physician, provider, hospital staff or representative, nurse, or other provider of services to the Client. Client s right to privacy and confidence is protected by current regulations. Client information will not be distributed or sold to any third party. 26) Privacy and Confidentiality - Except as described below, all test results are confidential and will not be intentionally disclosed or transmitted to any unauthorized person. All tests are performed for the safety of patients who may receive the umbilical cord blood and Cord Tissue for transplantation. We will attempt to inform you and your physician of any positive test results that may affect your health of the health of your baby. You acknowledge and agree that GeneCell International will not be liable for errors in test results or decisions based on erroneous test results. 27) Rights of Participants - If you have any questions about the GeneCell International Umbilical Cord Blood and Cord Tissue Banking Program, feel free to contact us at or Toll Free within the United States at Page 7 of 12

8 Signature of Mother I am at least 18 years of age and I am the biological birth mother of the baby. I have read and understand this consent and I have been given the opportunity to ask questions. All of my questions have been answered to my satisfaction. I have been given a copy of this consent. I agree to participate in the GeneCell International Cord Blood and Cord Tissue Program and my baby s umbilical cord blood and Cord Tissue may be collected, stored and used as described in this consent. Print Name of Mother Signature of Mother Date Signature of Person Obtaining Consent I certify that the nature and purpose, the potential benefits and possible risks associated with participation in the GeneCell International Cord Blood and Cord Tissue Program have been fully explained to the mother. The mother was given the opportunity to ask questions and all of her questions have been fully and completely answered. Print Name of Company Person Obtaining Consent Signature of Company Person Obtaining Consent Date SECTION 3 Medical and Health History Profile A medical health profile is required by regulatory agencies. Please complete the information below to the best your knowledge Mother s Full Name Social Security / ID # Date of Birth Address City State Zip Code Country Home Phone Work Phone Cellular Phone Expected due date Marital Status Baby s Name Father s Full Name Social Security / ID # Date of Birth Address City State Zip Code Country Home Phone Work Phone Cellular Phone OB/Midwife Full Name OB/Midwife Address City State Zip Code Country OB/Midwife Phone Number Hospital Name Hospital Address City State Zip Code Country Hospital Phone Number Page 8 of 12

9 Medical Health History Questionnaire Health of mother: Yes No Have you or the baby s father ever: Yes No Are you in good general health? Tested positive for hepatitis B or C? Are you currently taking any prescription medications? Tested positive for HIV/AIDS? Are you having any complications with this Tested positive for HTVL-I or II? pregnancy? Are you having a planned cesarean delivery? Been turned down as a blood donor or been diagnosed with Creutzfeldt-Jacob disease or west nile virus? In the past twelve months, have you or the baby s Received human pituitary growth hormone? father: Had any body piercings, a tattoo, an accidental needle stick, or been an intravenous drug user? Had anti-malarial medication or clotting factors for a bleeding disorder? Had malaria, chagas disease, or other parasitic disease? Had unexplained fever, swollen lymph nodes, or purple spots on your skin? Been exposed to anyone who has been diagnosed Has anyone in the maternal or paternal family had: with hepatitis? Been incarcerated in a correctional facility for more than seventy-two hours? Aplastic anemia, thalassemia, fanconi s anemia, sickle cell anemia, any metabolic storage disorder or any other genetic or inherited disorder? Been diagnosed with or exposed to tuberculosis or been in a malarial endemic country? Leukemia, SCID, Wiskott Aldrich Syndrome, or chronic granulomatosis? Had sexual contact with someone who is HIV positive or at high risk for HIV infection? Been diagnoses with a sexually transmitted disease? Had a blood transfusion or undergone an organ transplant? Please explain any yes answers that need further clarification (If it s necessary attach another page): Mother s Full Name Signature Date Father s Full Name Signature Date Page 9 of 12

10 SECTION 4 Next of Kin Information and Reference Info Next of Kind Full Name Address City State Zip Code Country Home Phone Cellular Phone The Next of Kin listed below is my: (Please select the individual below indicating your relationship to your next of kin. If no family is available select (Other) and indicate relationship to the person (i.e. neighbor, friend, partner, etc.): Spouse Mother Father Sister Brother Son Daughter Aunt Uncle Niece Nephew Cousin In-Law Other: Please select Type of Birth: SINGLE BIRTH TWINS TRIPLETS QUADRUPLETS How did you hear from us? Physician/Midwife Childbirth Class Medical Center Exhibit/Baby Show Mailer TV/Radio *Personal/Client Referral Facebook Twitter YouTube **Other *Referrer's Name: **Other (Provide more info): Page 10 of 12

11 SECTION 5 Storage Options The enrollment and processing fee is a onetime fee that covers the cost of enrollment, delivery of the collection kit to you and processing of the cord blood unit. Processing includes: red cell depletion, volume reduction and cryopreservation, Cord Blood Testing HBcoreAB, HBsurfaceAG, HIV I/II, HTLV I/II, RPR, CMV IgG/IgM, HCV, HIV, NAT, HCV NAT, WNV NAT, Bacterial and Mycology Cultures, CD34 with 7AAD viability and the issuance of certificate (6 to 8 weeks) with the total nucleated cell count of your baby s Umbilical Cord Blood. Client acknowledges that results of test performed by the independent laboratory are not guaranteed. The elimination of some errors is not possible due to the nature of the tests. The independent laboratory does not guarantee or warrantee the services. The Independent laboratory is not responsible for any losses or damages arising out of the services provided, unless and only to the extent caused by the independent laboratory s negligence or misconduct. CORD BLOOD PLANS: Plan Selection Cord Blood Storage Plans Prices Enrollment, collection kit ($ non-refundable), cord blood processing, cord blood testing, maternal blood testing and 1 st year storage. $1, Enrollment, collection kit ($ non-refundable), cord blood processing, cord blood testing, maternal blood testing and 5 year storage. $2, Enrollment, collection kit ($ non-refundable), cord blood processing, cord blood testing, maternal blood testing and 10 year storage. $2, Enrollment, collection kit ($ non-refundable), cord blood processing, cord blood testing, maternal blood testing and 20 year storage. $3, CORD TISSUE: AN OPTIONAL SERVICE The enrollment and laboratory fees are onetime fees that cover the cost of enrollment, collection bottle and handling of the Cord Tissue Unit. These fees also include Cord Tissue testing, Bacterial and Mycology cultures, preparation and cryopreservation of your baby s Umbilical Cord Tissue. Client acknowledges that results of test performed by the independent laboratory are not guaranteed. The elimination of some errors is not possible due to the nature of the tests. The independent laboratory does not guarantee or warrantee the services. The Independent laboratory is not responsible for any losses or damages arising out of the services provided, unless and only to the extent caused by the independent laboratory s negligence or misconduct. CORD TISSUE PLANS (MUST COINCIDE WITH CORD BLOOD STORAGE PLAN): Plan Selection Cord Tissue Storage Plans Prices Enrollment, collection bottle ($ non-refundable), cord tissue processing, cord tissue testing and 1 st year storage. $ Enrollment, collection bottle ($ non-refundable), cord tissue processing, cord tissue testing and 5 year storage. $ Enrollment, collection bottle ($ non-refundable), cord tissue processing, cord tissue testing and 10 year storage. $1, Enrollment, collection bottle ($ non-refundable), cord tissue processing, cord tissue testing and 20 year storage. $1, Prices valid for the contractual date only and are subject to change without notice. CORD BLOOD RENEWAL PLANS: CORD TISSUE RENEWAL PLANS: Cord Blood Renewal Prices Cord Tissue Renewal Fees Prices Fees 1 Year $ Year $ Year $ Year $ Year $ Year $ Year $1, Year $1, Mother s Full Name Social Security / I.D. # Signature Date Father s Full Name Social Security / I.D. # Signature Date Page 11 of 12

12 SECTION 6 Payment Processing Form Page 12 of 12