Release of Cord Blood - Over 16 | CordBank New Zealand

Release of Cord Blood for Medical Use - Child 16 and Over

I authorise CordBank to release my cord blood for use:(Required)

Name:

CK Number:(Required)

Date of Birth:(Required)

Email(Required)

Phone(Required)

Name of Medical Practitioner:(Required)

First Last

Email Address:(Required)

Practice Phone:(Required)

Mobile Phone:(Required)

Practice Address:(Required)

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

Intended Use of Cord Blood:(Required)

I confirm the cord blood will be used in the treatment of:(Required)

I confirm the above information is correct:(Required)

Yes

I confirm I am authorising the release of my cord blood to the above Medical Practitioner:(Required)

Yes

Today's Date:(Required)

(ie. Parent)

Name of Additional Contact 1:(Required)

First Last

Email of Additional Contact 1:(Required)

Phone of Additional Contact 1:(Required)

Name of Additional Contact 2:

First Last

Email of Additional Contact 2:

Phone of Additional Contact 2: