Cancellation and Return of Cord Blood 16+

Please complete the form below for cancellation of cord blood storage and return of cord blood

Confirmation of Contract Cancellation & Return of Cord Blood Unit - 16+

Name:(Required)

First Last

CK number:(Required)

Date of Birth:(Required)

Additional Contact

(ie. Parent)

Additional contact 1:(Required)

First Last

Additional contact 1 Phone:(Required)

Additional contact 1 Email:(Required)

Additional contact 2:

First Last

Additional contact 2 Phone:

Additional contact 2 Email:

Return Address:(Required)

I want my cord blood to be returned to this address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Confirmation

Please check each box to confirm you understand the terms of service for return of cord blood:

I give notice of cancellation of this contract with CordBank.

I am aged 16 or over.

I am the person whose blood is stored by CordBank under this contract.

I understand that my request to have the cord blood returned to me means that it will not be available for use for any purpose should I require it under any circumstances in the future.

I consent to the return of my cord blood.

I agree to meet the costs involved in the return of the cord blood unit.