Login   |   Register   |   Français
Call Us

Terms and Conditions

CBBC – Form 1 – Individual Account –  Client Service Agreement

 

Instructions: Client to complete and return to the CBBC.

This is a 3 page agreement between the Cord Blood Bank of Canada (“CBBC”) and expectant parent from here on referred to as (“client”) who wishes CBBC to provide processing, freezing, and cryogenic storage and maintenance services for Biological InsuranceTM .  Please sign agreement and initial each page in spaces provided.

  1. CBBC WILL PROVIDE FOR THE CLIENT:
  2. An Individual Account  The individual account will contain the information necessary for identification, account management and Client contact.
  3. Cord Blood and Cord Tissue Collection Kit. CBBC will provide the Client with a Collection Kit in advance of the expected due date.   Please note: The CBBC suggests that patients are enrolled by 32 weeks so that a collection kit can be received in advance of the expected due date.
  4. Instructions.  CBBC will provide educational materials for the Client’s physician/midwife.
  5. Receiving, processing, and cryogenic storage and maintenance of the collected cord blood and cord tissue cells. If the cord blood sample is eligible for storage, as determined by infectious disease marker testing and/or sterility, cell-count determination, viability testing
    1. CBBC will label it with your baby’s assigned unique identifier.
    2. CBBC will process, freeze, store, and maintain the stem cells at cryogenic temperatures.
    3. CBBC will test the collected cord blood for micro-organisms and/or cell count and/or viability tests.  If cord blood is determined unsuitable for transplantation and/or storage due to the presence of micro-organisms,  inadequate cell count and/or viability, the client will be advised.
    4. Retrieval of Sample for Use. At any time during the maintenance period, only the Client, the child’s legal guardian, the child after their 18thbirthday, or a proper court order can request CBBC, in writing, sent by certified mail, to retrieve and prepare the stored cells for transport to a designated location, in the event that the Client’s stem cell deposit becomes medically indicated.  The deposit will only be released upon the signing and completion of an “authorization and direction agreement for release of stem cell deposit form”, which permits the release of a deposit to a specified intended recipient, and with a “stem cell deposit release from liability form”, executed on or behalf of the recipient, releasing the CBBC, and any involved physicians, hospital, directors, officers, employees, from any liability which may arise in connection with the use of the deposit.  Client is responsible for costs of preparation and shipment of the cord blood and cord tissue cells.  The sample may only be released to a physician upon consultation with and approval of the CBBC scientific director to a transplant-approved site and upon payment of the sample preparation fee.
    5. By shipping your baby’s Biological InsuranceTM(cord blood and/or cord tissue) sample to the CBBC laboratory, THE CLIENT AGREES TO BE RESPONSIBLE FOR:   

1 )Review of materials.  All literature contained in the Cord Blood Bank of Canada information packet should be read and fully understood before signing any documents. Enrollment forms completed accurately and returned in a timely manner.  Enrollment forms include: Client Service Agreement, Informed Consent, Limitation of Liability and Release, Medical Health History, and Authorization for release form

2)  Providing a Maternal blood sample after collection of cord blood.  A Maternal blood sample kit  (enclosed in the collection kit  – 3 vials) and instructions for collection are  enclosed.  A maternal blood sample must be collected within 30 days of cord blood collection.

  1. Payment of Enrollment fee (collection kit) and shipping fee.  Once either your baby’s: enrollment forms (forms 1-5), online enrollment or telephone enrollment is received an enrollment fee of $150 + tax plus shipping will be billed to your credit card. Your Collection Kit will be released at this time.  This fee is non-refundable.  Please contact your care manager for collection kit shipping fee details. (twin: $225 + tax + shipping, triplet: $275+ tax + shipping)
  2. Communication to the delivering physician/midwife.  Notification to the Client’s physician/midwife of the desire to collect their baby’s cord blood.  Signing, the Limitation from Liability and Release.This form releases your physician/midwife and hospital and all associated services from liability. Providing CBBC with the Informed Consent for collection and testing of maternal blood sample and collection and storage of cord blood and cord tissue if applicable.  This form contains your authorization to have your maternal blood sample and your baby’s cord blood and cord tissue collected.  This consent must be received prior to delivery and must be signed by you.
  3. Providing CBBC with a completed and signed copy of the Cord Blood Sample confirmation form.
  4. Making shipping arrangements.  The client is responsible for the express shipment of the samples to CBBC’s laboratory.  The Client must contact the CBBC within 3 hours of the collection of the cord blood in order to notify CBBC of such collection.  It may not be possible to process and store the Biological InsuranceTM sample if CBBC is not promptly notified.  The samples SHOULD BE SHIPPED IMMEDIATELY and should be received by the laboratory within 24-36 hours of collection using the packaging and kit provided by CBBC.  The Client is responsible for shipping costs.

Form 1 – Page 1 of 3  Initial  __________     __________     __________

 

 

 

  1. Notification to CBBC of the shipping arrangements. The Client MUST CALL to notify CBBC of successful collection of cord blood, and tracking details if applicable.
  2. Payment of courier fee – shipping cost from delivering facility to CBBC laboratory. Fee will be billed to Client when the Biological InsuranceTM sample is received in the CBBC laboratory if has not already been paid for by the client, please contact care manager for further details.
  3. Payment of annual storage fee(s).Fee(s) will be billed annually in the birth month of your child. The annual storage fee is currently at 150 + HST.  This is subject to change.  Any changes to the annual storage fee will be posted to the Cord Blood Bank of Canada website.  It is the client’s responsibility to check the CBBC website for any fee changes.
  4. Notification to CBBC of any changes in address and billing information and payment of administration fees and or late fees if applicable. The Client agrees to notify CBBC of all changes in telephone number, address, and payment information while this Agreement is in effect.  The client agrees to pay any administration and or late fees incurred in maintaining the client’s account on the day that they are billed.
  5. Sterility Testing. Despite rigorous collection procedures, due to the microorganism contamination risk inherent in the delivery process, current medical data suggest cord blood may be contaminated with micro-organisms. Sterility testing of the cord blood will assist in the evaluation of the suitability of contaminated cord blood for storage and/or transplantation and is at the discretion of the scientific director.
  6. Cell Count Determination Once your baby’s cord blood reaches our laboratory the cell count will be determined.  If the collected cord blood is determined to have a low cell count, the cord blood is unsuitable for transplantation and therefore unsuitable for storage.  This will be communicated to the Client.
  7. Q.     Viability Testing Once your baby’s cord blood reaches our laboratory a viability test of the cord blood cells will be performed.  If the cells contained in the cord blood are determined to be unviable, the cord blood will not be eligible for storage and the client will be advised immediately.
  8. Payment of cord blood tissue processing fee.By enclosing a cord tissue sample, the client elects to have his/her baby’s cord blood tissue processed and stored.  This fee will be billed to Client when your baby’s biological InsuranceTM sample reaches theCBBC laboratory.
  9. Payment of Enrollment fees: Processing, testing, 1styear annual storage  All fees for the enrollment, processing, testing and 1st year storage of your baby’s Biological InsuranceTM cord blood and cord blood tissue are payable once your baby’s Biological InsuranceTM  sample reaches our laboratory.   In the event that any fees that are due are not able to be billed at any time: due to outdated credit card or invalid credit card information, or any other reason, late payments are subject to an administration fee of $25 + tax.  This administration fee may be applied to monthly payments and/or any other payment due to the CBBC as per contract.   Each late payment is subject to a monthly $25 + tax administration fee.   In addition to the administration fee, all outstanding payments are subject to an annual interest rate of 19%.

III.  GENERAL

CBBC cannot guarantee that your baby’s Biological InsuranceTM will be collected.  The health of the mother and baby will be your physician/midwife’s first priority, complications may occur during birth which may preclude the collection of the cord blood.  Eligibility for Individual Account storage cannot be fully assessed until the cord blood is processed at our laboratory.  Should collection not occur, no additional fees will be billed.  If the maternal blood sample tests positive for any of the following infectious disease markers :(HIV, Hepatitis B, VDRL, HTLV, Hepatitis C), at any time, the sample is ineligible for storage and no fees will be refunded.  CBBC maintains the right to discard any  sample in accordance with our standard operating procedures.  CBBC maintains the right to reject any Biological InsuranceTM  sample at any time and without notice.

  1. TERM AND TERMINATION  

This agreement will commence on the effective date as set out below.  When the child becomes an adult, he or she will acquire the rights in the Biological InsuranceTM sample and will execute an agreement with CBBC similar to this one.   CBBC will contact the client prior to the child reaching 18 years of age in order to obtain and execute a copy of the then current agreement.  The client acknowledges that CBBC will rely on this agreement until such time as either 1) CBBC receives an executed copy of the then current agreement from the child, or 11) this agreement is terminated in accordance with its terms as set out below.  The client understands and agrees that the client is signing this agreement on behalf of the child.  The Client agrees to indemnify and save harmless CBBC, its shareholders, directors, officers and employees in the event that a claim is made at any time, directly or indirectly, by or on behalf of the child for any matter that the client has agreed pursuant to this agreement.  The client may terminate this Agreement at any time upon written notice to CBBC.  This notice must include a direction to 1)destroy the Biological InsuranceTM sample and a sample destruction fee will become payable.  This fee is subject to change and is to be determined at the sole discretion of the CBBC or 11) donate the Biological InsuranceTM sample to research.   If the client fails to provide direction for the cord blood as outlined above within sixty (60) days of termination of this agreement, the client agrees that 1)any and all right or title and interest (including any intellectual property rights) that the client or child  may have otherwise had in respect to the Biological InsuranceTM sample will be assigned to CBBC and,  11) CBBC will own all such right, title and interest and the client hereby authorizes CBBC and  to use the specimen at its sole discretion to either destroy the sample or use it for research purposes.  The client further understands that if the agreement is terminated the client will not be entitled to any refund previously paid by the client to CBBC.

CBBC may terminate this agreement at any time if payment is not received within 30 days of its due date without notice.  CBBC encourages the client’s direction with regards to the following options: 1)destroy the Biological InsuranceTM sample, or 11) donate the Biological InsuranceTM sample to research purposes.  If the client fails to provide direction for the cord blood as outlined above within sixty (60) days of termination of this agreement, the client agrees that 1)any and all right or title and interest (including any intellectual property rights) that the client or child  may have otherwise had in respect to the Biological InsuranceTM sample will be assigned to CBBC and,  11) CBBC will own all such right, title and interest and the client hereby authorizes CBBC and  to use the specimen at its sole discretion to either destroy the sample in order to use it for research purposes.

 

Form 1 – Page 2 of 3  Initial  __________       __________     __________

 

This Agreement, together with the Informed Consent (FORM 2) , the Limitation of Liability and Release Form (FORM 3), and the Medical Health history Form (FORM 5) constitutes the entire Agreement between the parties and supersedes all previous Agreements or representation, oral or written, relating to the subject matter of this Agreement.  This Agreement may be modified or amended at any time by CBBC without notice.  If the performance of this Agreement or any obligations arising under this Agreement is prevented, restricted, or interfered with by reason of fire, earthquake, or other casualty or accident, strikes or labour disputes, war or other violence, any law, order, proclamation, ordinance, demand, or requirement of any government agency, or any other act or conditions beyond the control of CBBC, CBBC, shall be excused from such performance. Both parties acknowledge they have read this Agreement, understand its terms and conditions, and agree to be bound by it. If any provision of this Agreement is held by a court of competent jurisdiction to be invalid, void or unenforceable, the remaining provisions shall nevertheless continue in full force without being impaired, or invalidated in any way.  CBBC assumes no liability for any defects or workmanship in the materials contained in the Collection Kit or storage materials used.  CBBC is not responsible for procedures or services performed by third parties including, but not limited to, collection, lab tests, transport, improper handling, or use during transplantation. I, the client, hereby accept this agreement to be fair and reasonable.  I am signing this agreement voluntarily.  The terms of this agreement will be binding on me, my heirs, executors, administrators, guardians, attorneys and trustees.

Effective, this __________ day of _______________________, ____________

Day                                          Month                      Year

 

_______________________________________          _______________________________________  _______________________________________

Signature of Client(s)                                                                                        Signature of Client(s)                                                                                        Signature of Witness

_______________________________________          _______________________________________  _______________________________________           Name of Client(s)                                                                                                              Name of Client(s)                                                                                                                        Name of Witness

 

PAYMENT AUTHORIZATION :PLEASE ENSURE THE PAYMENT INFORMATION BELOW IS FILLED OUT COMPLETELY.  Incomplete information may delay processing your sample.  I understand that all payments are non-refundable.  I authorize CBBC to bill the following Credit Card:

_________________________________              _______________         _____________________________________________

Card Number                                                                                                                                                  Expiry Date                             Billing Address (if different)

 

_________________________________                                                                                                                       _____________________________________________

Authorized Signature

 

_________________________________               _____________________________________________

Name on Card                                                                                          E-mail address

  1. Once enrollment has been received by the CBBC, $150 + tax + collection kit courier fee (consult care manager for details) will be billed to the above credit card for your baby’s account.  (if enrolling twins$225 + tax, triplets $275 + tax will be billed).
  2. If enrolling TWINS, please check here _______      If enrolling TRIPLETs, please check here ______
  3. Once your baby’s Biological InsuranceTM sample reaches CBBC’s laboratory the remaining portion of the enrollment fees ($975 + tax + shipping) plus any applicable courier fees will be billed to the above credit card for your baby’s account. (twin: $1425+ tax + shipping, triplet: $1875 + tax + shipping)
  4. Please check here if you are enrolling a subsequent baby:________   If enrolling a subsequent baby only $875 + tax + shipping will be billed.
  5. Once your baby’s Biological InsuranceTM sample reaches CBBC’s laboratory, if there is a cord blood tissue sample enclosed, the above credit card will be billed $600 + tax (twin: $1000 + tax, triplet:$1375 + tax).
  6. Your credit card will be billed $150+tax in your child’s birth month annually in the future ($275 + tax if a cord tissue sample was enclosed).
  7. If twins were enrolled, your credit card will be billed $300 + tax in your child’s birth month in the future ($500 + tax if cord tissue sample were enclosed)
  8. If triplets were enrolled, your credit card will be billed $450 + tax in your child’s birth month in the future ($575 + tax if cord tissue samples were enclosed).

Please enter discount code if any: ___________

 

PAYMENT OPTIONS:  Once your baby’s Biological InsuranceTM sample reaches our laboratory all outstanding enrollment and optional services fees are due.  Choose to pay all outstanding fees in full or choose one of our convenient payment plan options.   

_____ Please bill me in full once my baby’s Biological InsuranceTM sample reaches the CBBC laboratory.

_____ Please bill me $300 + tax monthly.  (3 monthly payments: 1st, 2nd, 3rd months @ $300 +tax , (4th month @ $200 + tax + Biological InsuranceTM  courier fee).  For cord tissue add 2@ 300 + tax)

 

Form 1 – Page 3 of  3

 

CBBC – Form 2 Individual Account – Informed Consent for Collection and Storage of Cord Blood, Cord Tissue and collection and testing of Maternal Blood Sample

 

Instructions :This is a 2 page form for the  client to complete by reading, signing and initialing where indicated  and returning it  to the Cord Blood Bank of Canada (CBBC).

On behalf of myself and my unborn baby, I, the Client, wish to enroll in the Individual Account offered by the CBBC. 

 

 

THIS CONSENT AGREEMENT CONVEYS THAT I, THE CLIENT, FULLY UNDERSTAND AND CONSENT TO THE FOLLOWING: 

 

1)                   That the Individual Account offers storage for stem cells contained in cord blood and cord tissue.  The sample will be uniquely identified, stored, and maintained at a cryogenic storage facility.  CBBC will retrieve these cells at my request per the Client Service Agreement provided that my account is in good standing.

2)                   That it is not possible to determine whether my child will develop a disease in the future which can be treated by these cells.

3)                   That I must provide the CBBC with a maternal blood sample collected within 30 days  after the cord blood is collected.

4)                   That if my blood tests positive for HIV, HTLV, Hepatitis B, Hepatitis C, and/or syphilis  at any time, my baby’s Biological InsuranceTM will be ineligible for storage and transplantation.

 

5)                   COLLECTION OF CORD BLOOD & CORD TISSUE

  1. a) That collecting and storing my baby’s cord blood and/or cord tissue stem cells may potentially benefit my baby should he/she need them in the future to treat certain diseases.
  2. b) That these stem cells are a perfect match with my baby and, while there is no guarantee my baby will ever need them, the fact that they are a perfect match can reduce serious complications should cell therapy ever be needed.
  3. c) That, although infrequent, complications may occur at birth and it may not be possible for my physician/midwife to collect the cord blood.  Therefore, collection of cord blood cannot be guaranteed since its collection is arranged between me and my physician/midwife. My health and the health of my baby is my physician/midwife’s first priority.  I agree that my physician/midwife’s judgment shall be absolute and final.  I shall not hold my physician/midwife, nurses, the hospital and/or its staff responsible or liable for any arrangements, procedures, or handling of the cord blood.

 

6)                   RECEIPT AND PROCESSING OF CORD BLOOD:

  1. a) By sending my baby’s collected cord blood and/or cord tissue to CBBC’s processing laboratory, I understand that the sample will be processed and fees will be incurred per the Client Service Agreement.  
  2. b) That volumes of less than 25ml of cord blood have been processed, obtaining a sufficient number of viable stem cells.
  3. c) That there is no way of knowing if the cord blood and/or cord tissue sample can be stored until it is assessed at CBBC’s laboratory.  If the sample is questionable, or test results unavailable, an attempt will be made to contact me and find out my instructions as to the disposition of the sample.  CBBC maintains the right to reject any cord blood sample at any time.  There is no guarantee that my baby’s stem cells will survive the separation, cryopreservation (freezing), or thawing procedures.

 

7)              TESTING OF COLLECTED CORD  BLOOD: Sterility Testinga)

I understand that despite rigorously controlled collection procedures, due to the micro-organism contamination risk inherent in the birth process, current medical evidence suggests that 1-13% of collected cord blood may be contaminated.

  1. b)   I understand that contaminated cord blood may be unsuitable for transplantation.
  2. d)   I understand that by requesting the CBBC to test my baby’s collected cord blood for the presence of micro-organisms, although the CBBC will do its best to determine the sterility of the cord blood, as with any test, false negatives and false positives may occur.

 

8)              TESTING OF COLLECTED CORD  BLOOD: Cell Count Determination

  1. a)  I understand that nucleated cell count is correlated with increased transplant survival.
  2. b)  I understand that my baby’s cord blood could be found to contain inadequate numbers of nucleated and/or viable cells for transplantation.
  3. c)   I understand that if my baby’s cord blood is determined to have a low cell count, I will be contacted immediately, and my baby’s cord blood will be ineligible for storage and transplantation.
  4. d)   I understand that by requesting the CBBC to test my baby’s collected cord blood for a cell count determination, although the CBBC will do its best to determine the cell count of the cord blood, as with any test, false negatives and false positives may occur.

 

8)              TESTING OF COLLECTED CORD  BLOOD: Viability Testing

  1. a)  I understand that only viable cells are suitable for transplantation.
  2. b)   I understand that if my baby’s cord blood is determined to consist of mostly unviable cells, I will be contacted immediately, and my baby’s cord blood will be ineligible for storage and/or transplantation.
  3. c)   I understand that by requesting the CBBC to test my baby’s collected cord blood for viability, although the CBBC will do its best to determine the viability of the cells of the cord blood, as with any test, false negatives and false positives may occur.

 

 

Form 2 – Page 1 of 2  Initial  __________     __________     __________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9)   COLLECTION and TESTING OF MATERNAL BLOOD: 

A maternal blood sample must be collected within 30 days of birth.  The maternal blood sample may be  screened at any time for human immunodeficiency virus (HIV), hepatitis B and hepatitis C virus, human T-lymphotrophic virus (HTLV), cytomegalovirus (CMV), syphilis.  If the test results of your blood sample are confirmed positive for HIV, Hepatitis B, HTLV, hepatitis C, and/or syphilis, the cord blood and cord tissue will not be eligible for storage and transplantation.   I UNDERSTAND and I authorize the CBBC to have my maternal blood sample tested for the above infectious disease markers by its contracted private licensed laboratory.

 

11)    BENEFITS and RISKS:  I UNDERSTAND that there are benefits and risks relating to the collection of cord blood and/or cord tissue samples.  The benefits of cord blood collection include the long-term storage of stem cells that could be used as part of a treatment program for a variety of life threatening diseases and conditions, including heart and brain regeneration, leukemia, certain cancers, and blood disorders.  A potential risk is that therapy using stem cells may not be effective or not appropriate for the treatment under consideration.

 

12)    OTHER ALTERNATIVES: I UNDERSTAND that other sources of stem cells exist, including bone marrow, peripheral blood, and embryo and they or may have not as of yet been tested in some applications.  While bone marrow is currently the most common source of stem cells for application in blood disorders, heart and brain regeneration, collecting stem cells from bone marrow is costly, requires an invasive procedure, and carries the risk of infection and surgical complications.  Should a stem cell donor be needed later, finding a suitable match can be expensive, may take a long time, or may not be successful.   The collection of stem cells from peripheral blood involves the use of lengthy procedures in which your blood is pumped through a machine for several hours.  In the future, other ways of treating these diseases may be found, so that the cord blood cells stored under the Individual Account may not be necessary.

 

13)     STORAGE OF STEM CELLS: I UNDERSTAND that the freezing and storage process used to preserve stem cells harvested from cord and placental blood and tissue is similar to the process that is currently used for storing other human cells, and that although this freezing technique has been used for many years to successfully preserve bone marrow and other blood cells, it has been used to store cord blood stem cells only in the last 25 years.  Laboratory studies and transplants utilizing frozen stem cells suggest that this process can be used successfully with cord blood stem cells.  I UNDERSTAND that there is no guarantee that my child’s stem cells will survive the separation, cryopreservation (freezing), or thawing procedures.  I UNDERSTAND that there is a possibility that the collection or storage system may fail with consequent loss of stem cell deposits.

 

14)    USE OF STEM CELLS: Although the preservation and potential use of umbilical cord blood and tissue is expanding rapidly, the odds that a baby without a defined risk will ever use his/her stem cells are low and may never be needed.  There is no guarantee that the stem cells will benefit your baby or that a stem cell transplant will provide a cure.  As with any transplant therapy, therapeutic success depends upon many factors beyond the stem cells themselves including patient condition, type of disease, and other factors.  The decision to use stored stem cells for transplantation must be made in careful consideration with your treating physician.  I UNDERSTAND that the use of stem cells collected from umbilical and placental blood and tissue is still considered to be “experimental”.  Possible current benefits from the use of stem cells may be limited to certain life-threatening diseases, including leukemia, certain cancers, and heart and brain regeneration. Potential risks include the possibility that this type of treatment may not be effective.  I UNDERSTAND that stem cells are not the treatment of choice for all diseases or conditions and that should the need arise, the decision to use the stem cells stored under the Individual Account is strictly between me, CBBC and the attending physician.  It is possible that in the future better therapies may be developed.  I UNDERSTAND that there is no guarantee that successful transplantation will occur using my child’s stored stem cells.

 

I UNDERSTAND that my obstetrician or certified nurse midwife will make the final decision as to when and if my child’s cord blood and/or tissue will be collected.  I understand that, although infrequent, complications may occur at birth and it may not be possible for my obstetrician or certified nurse midwife to collect my child’s cord blood and/or tissue.  My health and the health of my baby are the first priorities.  Accordingly,

 

I hereby consent to the following procedures:

 

  • I consent to have my obstetrician or certified nurse midwife collect the cord blood and/or tissue after the birth of my child.  I consent to the cell viability, total cell number, infectious disease markers, and/or microorganism tests that will be performed on my child’s cord blood unit and/or my maternal blood sample to determine the nature and quality of the cord blood.

 

I understand that appropriate confidentiality will be maintained for all patient records concerning the Service but that the Department of Health or other government agencies may inspect records in accordance with applicable Local, Provincial, or Federal laws or regulations.  I have read and understand this informed consent and know that I can refuse the Service without prejudice.  I have signed this consent freely and voluntarily.

 

I certify that I have read the preceding or it has been read to me, that I understand its contents, and that any questions I have pertaining to this Informed Consent and the Service Agreement have been answered.

 

Signed this __________ day of _______________________, _____________

Day                                          Month                      Year

 

_______________________________________          _______________________________________  _______________________________________

Signature of Client(s)                                                                                        Signature of Client(s)                                                                                        Signature of Witness

 

_______________________________________          _______________________________________  _______________________________________

Name of Client(s)                                                                                                Name of Client(s)                                                                                                 Name of Witness

 

 

Form 2 – Page 2 of 2

 

 

CBBC – Form 3 – Individual Account – Limitation of Liability and Release 

 

I desire to have my child’s Biological InsuranceTM collected at the time of delivery and stored through the Cord Blood Bank of Canada’s (CBBC) service.  I understand that the Service involves new medical procedures and that, my health and the health of my baby are of primary concern.  Therefore, the decision whether or not to perform the cord blood and/or cord tissue collection will be at the sole discretion of the attending obstetrician or certified nurse midwife.

 

In consideration of the opportunity to use CBBC’s Service:

 

  1. I understand and agree that, I hereby release CBBC and its officers, directors, employees, physicians, agents, affiliates, successors and assigns from any and all liability, for any and all: loss, harm, damage or claim of any kind which may arise in connection with my child’s cord blood and/or cord tissue collection, processing, storage, and preservation (including associated record keeping), transportation, disposal or destruction (whether accidental or intentional), release, and/or any use to which it may be put, however such liability may arise.  I further agree to release CBBC from any and all claims, actions, suits, complaints or demands whatsoever that may be asserted by any other person in connection with this agreement.  I understand that by this release I am giving up any right I might otherwise have, now or in the future, to sue or otherwise seek money damages or other relief against CBBC for any reason relating to the Service.

 

  1. In addition, I hereby release my obstetrician or certified nurse midwife, the hospital or birthing center, and all of their officers, directors, employees, agents, affiliates, successors and assigns from any and all liability for any and all loss, harm, damage or claim of any kind in connection with the collection of the cord blood and/or cord tissue unit.  I understand that by this release I am giving up any right I might otherwise have, now or in the future, to sue or otherwise seek money damages or other relief against my obstetrician or certified nurse midwife, the hospital or birthing center, for any reason relating to the collection of the cord blood and/or cord tissue unit.

 

By signing this Limitation of Liability and Release Form, I hereby acknowledge that I am giving up legal rights I might otherwise have had, and that I have signed it knowingly and voluntarily.

 

 

 

Signed this __________ day of _______________________, _____________

Day                                          Month                                                                          Year

 

 

_______________________________________          _______________________________________  _______________________________________

Signature of Client(s)                                                                                        Signature of Client(s)                                                                                        Signature of Witness

 

_______________________________________          _______________________________________  _______________________________________

Name of Client(s)                                                                                                 Name of Client(s)                                                                                                 Name of Witness

 

 

 

 

 

 

 

 

CBBC – Form 4 – Authorization for Release of Information

 

 

 

I _______________________________________, ______________________

Patient’s Full Name                                                   Date of Birth (dd/mm/yyyy)

 

 

___________________________________________________    ________________________________   ___________________

Address                                                                                                                                                               City/Postal Code                                                              Province

 

_________________________________________              ______________________________________

Tel (home)                                                                               Tel (work)

 

 

 

hereby authorize _________________________________________

Institution or Practitioner (General practitioner for the mother’s overall health care)

 

 

to forward any necessary maternal blood test results and/or any records to the Cord Blood Bank of Canada for the purpose of further medical treatment.

 

 

I understand the private and confidential nature of this information and consent to it being used only for the purpose of further medical treatment.  I hereby release the information-releasing institution/practitioner of any liability that may result from the release of this information.

 

 

Signed this date of ____________________________

Date  (dd/mm/yyyy)

 

 

__________________________________________         __________________________________________

Patient’s Name                                                                                                                                           Witness Name

 

 

__________________________________________            __________________________________________

Patient’s Signature                                                                                                                                  Witness Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CBBC – Form 5 – Individual Account – Medical Health History

 

(Instructions – to be completed by client)

 

 

 

__________________________________________________

Mother’s Full Name

 

__________________________________________________

Address

 

__________________________________________________

City/Postal Code                           Birth Date

 

__________________________________________________

Home Phone No.                           Work Phone No.

 

__________________________________________________

Occupation                                    Health Card NO.

 

__________________________________________________

Place of Birth

 

  1. Have you had any complications with this                                Y         N

or any other pregnancies?

  1. Have you ever been pregnant before?                               Y         N

How many times? _________

# of C-sections___ # vaginal deliveries___

  1. Have you had any pre-mature deliveries?               Y         N
  2. If so, at how many weeks? _________
  3. In the past year have you taken any medicine?             Y         N

 

HAVE you (the mother to be) ever, and/or do you currently:

 

  1. Have active encephalitis or meningitis of                      Y         N

viral or unknown etiology?

  1. Had rabies or been bitten by animal and treated    Y         N
  2. Had seizures, convulsions, or fainting spells or                 Y         N

been refused as a blood donor?

  1. Have a neurological disease of an unestablished         Y         N

etiology?

  1. Had any infections, surgery or serious illness:       Y         N

cancer, diabetes, heart or lung disease, chest pains,

asthma, neurological disease, or any malignancy?

  1. Have babesiosis, Chagas’ or prion related disease?   Y          N
  2. Test(ed) positive for:  HIV (Aids), HTLV1&2,                Y         N

syphilis, Hepatitis B, or Hepatitis C?

  1. Receive(d) human-derived pituitary growth                   Y         N

hormone or dura mater?

  1. Stay or live in a malaria or Zika endemic country as per          Y         N

CDC or Health Canada in the past 3 years?

  1. Received blood, blood products, derivatives, and/or    Y         N

clotting factor concentrates in the past 12 months?

  1. Have close contact with another person having            Y         N

clinically active viral hepatitis (e.g., living in the same

household, where sharing of kitchen and bathroom facilities occurs regularly) within the past 12 months?

  1. Tested positive or had treatment for gonorrhea,     Y         N

syphilis or any other sexually transmitted disease in

the past 3 years?

  1. Been exposed in the preceding 12 months to known      Y         N

or suspected HIV, HBV or HCV-infected blood through

percutaneous inoculation or through contact with an

open wound, non-intact skin, or mucous membrane

  1. Been an inmate of a correctional system (including      Y         N

jails and prisons) and/or been incarcerated for more

than 72 hours during the past 12 months?

 

__________________________________________________

No. of Weeks Pregnant Today                                    Due Date

 

Anticipated Birth: Planned C-section________  Natural birth_______

 

__________________________________________________

Delivering Hospital/Birthing facility                           Phone No.

 

__________________________________________________

Hospital/Birthing facility address                               Phone No.

 

__________________________________________________

Physician’s/Midwife’s Name                                        Phone No.

 

__________________________________________________

Partner’s Full Name

 

__________________________________________________

Place of Birth                                 Date of Birth

 

__________________________________________________

Occupation                                    Work Phone No.

 

__________________________________________________

Health Card NO.

 

  1. Have you (the mother to be) personally:
  2. engaged in sex for money or drugs in the                  Y         N

preceding 5 years

  1. had/have hemophilia or related clotting disorders    Y         N

and received human-derived clotting factor

concentrates?

  1. taken a non-medical intravenous, intramuscular            Y         N

or subcutaneous injection of drugs in the preceding

5 years?

  1. had sex in the preceding 12 months with any          Y         N

persons described in items (A) to (C) and/or with a

man who had sex with another man in the preceding

5 years and/or had sex with a person known or

suspected to have HIV, clinically active HBV or HCV?

  1. Received any vaccinations in the past 3 months?         Y         N
  2. Have an active leukemia or lymphoma?                       Y         N
  3. Been outside of Canada in the past 5 years?                   Y         N
  4. Have/had a tattoo, ear piercing or body piercing,          Y         N

and/or acupuncture, in the past year in which

shared instruments were used?

 

        HAS ANYONE IN THE MATERNAL OR PATERNAL FAMILY:

  •     had aplastic anemia, Fanconi’s anemia          Y         N

sickle cell anemia or thelessemia?

  • had chronic granulomatosis?                          Y         N
  • Had Hurler syndrome?                                                      Y         N
  • Had retinoblastoma?                                          Y         N
  • Had Severe Combined immunodeficiency                      Y         N
  • Syndrome?
  • had Wiskott-Aldrich syndrome?                                      Y         N
  • Had Wilms’ tumor?                                             Y         N
  • Had any specific genetic diseases?                               Y         N
  • Had Creutzfeld Jakob disease (CJD)?                Y         N
  • Had a family history of CJD?                               Y         N
  • Had subacute sclerosing panencephalitis, rabies,              Y         N

progressive multifocal leukoencephalopathy?

 

PLEASE EXPLAIN ANY “YES’ ANSWERS TO THE QUESTIONS ABOVE, STATE # 

 

____________________________________________________________________________________________________________________________________

 

____________________________________________________________________________________________________________________________________

 

I certify that I have answered the above answers truthfully and to the best of my knowledge.

 

_____________________________________ d/____m/____y/____                           _____________________________________ d/____m/____y/____

Client signature                                                                                                    Date                                                 Partner signature                                                                                                                        Date

shadow line