Contract Renewal

Phone

This field is for validation purposes and should be left unchanged.

Name:(Required)

First Last

CK Number:(Required)

Date of Birth:(Required)

DayDay12345678910111213141516171819202122232425262728293031

MonthMonth123456789101112

YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Phone:(Required)

Email:(Required)

I consent to the continuation of my cord blood storage:(Required)

Yes

Additional Contact

(ie. Parent)

Primary Additional Contact Name:(Required)

First Last

Email(Required)

Phone(Required)

Secondary Additional Contact Name:

First Last

Email

Phone

Payment

Payment Options

Select one

Annual payments of $225 per year by credit card. If “Annual payments” is selected in the online acknowledgement, the Parents and the Child together agree to pay to CordBank $225 per year for the storage of the cord blood (subject to any change to that amount under clause 10 or 17 of the Contract). CordBank will contact you to obtain the credit card details to be used to make the annual storage payment within 7 days.

Prepayment in one sum of $3,690 now for a further 18 years storage being $205 per year including GST. If “Prepayment” is selected in the online acknowledgement, the Parents and the Child together agree to pay $3,690 within 7 days. That will pay for storage of the cord blood for a further 18 years. CordBank will contact you to obtain payment within 7 days.

Confirmation

Parental Consent(Required)

Yes

Adult Child Consent(Required)

Yes

Submit