Cord Blood Bank of Canada

CBBC's Express Online Enrollment

Welcome to CBBC's Express Online Enrollment!

After you submit your information to us, your collection kit will be released to you within 1-5 business days.

* = Required Fields

MOTHER'S INFORMATION
* Mother First Name:		* Mother Last Name:
* Health Card Number:		Most Convenient Time to Contact You:
* Address:
* City:		* State/Province:
* Postal Code:
* Phone:		* E-mail:
* Expected due date:
# of weeks pregnant:		Delivering Hospital:
Natural/C-section anticipated delivery method:
Physician/Midwife Name:		Physician/Midwife Address:
Is this a twin enrollment?	Yes No
Have you had any complications with this or any other pregnancies?			Yes No
Have you ever been pregnant before?			Yes No
How many times?
Have you had any pre-mature deliveries?			Yes No
If so, at how many weeks?
In the past year have you taken any medicine?I if yes, please explain:			Yes No
HAVE YOU OR YOUR PARTNER EVER?
Taken human growth hormones?			Yes No
Been diagnosed with a blood or bleeding disorder?			Yes No
Had seizures, convulsions, or fainting spells?			Yes No
Been refused as a blood donor?			Yes No
Had any infections, surgery or serious illness: cancer, diabetes, heart or lung disease, chest pains, asthma, leukemia, lymphoma, or any malignancy? If yes, please explain			Yes No
Had hepatitis, yellow jaundice, tuberculosis, liver disease or a positive test for hepatitis?			Yes No
Had babesiosis or Chagas' disease?			Yes No
Been HLA tissue typed?			Yes No
Donated blood or a blood component transfused to a patient who later developed evidence of hepatitis, HIV or HTLV-1/2?			Yes No
Tested positive for HIV? HTLV1&2?			Yes No
Been at risk for AIDS?* *You may be at risk if you have multiple partners, have taken intravenous drugs, taken or paid money/drugs for sex, been in a correctional facility for more than 72 hours or are a hemophiliac. Please ask your doctor if you require additional information.			Yes No
Been or lived in a Malaria endemic country?			Yes No
Been or lived in Africa since 1977?			Yes No
Had malaria or taken anti-malaria drugs?			Yes No
Received blood, blood products, derivatives, or a tissue or organ transplant, human derived pituitary growth hormone, dura mater? If yes,please explain
Tested positive or had treatment for a. syphilis or gonorrhea b. any other sexually transmitted disease?			Yes No Yes No
Had close personal or sexual contact with someone diagnosed with or who has been exposed to: hepatitis, HIV (Aids), HTLV1&2, Syphilis or any other transmittable disease?			Yes No
Received any shots or vaccinations?			Yes No
Suffered from unexplained weight loss, fever, night sweats, swollen lymph glands, persistent cough or purple spots on the skin?			Yes No
HAS ANYONE IN THE MATERNAL OR PATERNAL FAMILY:
Had aplastic anemia, Fanconi's anemia sickle cell anemia or thelessemia?			Yes No
Had chronic granulomatosis?			Yes No
Had Hurler syndrome?			Yes No
Had retinoblastoma?			Yes No
Had Severe Combined immunodeficiency Syndrome?			Yes No
Had Wiskott-Aldrich syndrome?			Yes No
Had Wilms' tumor?			Yes No
Had any specific genetic diseases?			Yes No
Had Creutzfeld Jakob disease (CJD)?			Yes No
Had a family history of CJD?			Yes No
Had subacute sclerosing panencephalitis, rabies, progressive multifacial leukoencephalopathy?			Yes No
If yes to any of the above, please explain
I certify that I have answered the above answers truthfully and to the best of my knowledge.			Yes No
A care manager will contact you within 24 business hours in order to arrange for payment. Payment is required in order to ship your collection kit. Payment call also be arranged by calling us at (905) 943-4933 or toll free at 1-866-366-7057
How did you hear about the Cord Blood Bank of Canada?

PAYMENT OPTIONS (please select one) Full payment at enrollment Monthly payment plan 3 payment plan Enter discount code if any
I have read Forms 1-5*** and agree to forward all blood test results as required. I consent to Client Service Agreement and hereby authorize my consent to all. I hereby authorize CBBC to bill my credit card the appropriate fees* as per client service agreement. I do not give my consent and do not wish to bank my baby's cord blood. NOTE: All applications are subject to approval by our medical director. If you have any questions, contact a Care Manager.

**: Your credit card must be used to secure your enrollment with CBBC
***: Cord blood will not be processed unless accompanied by fully completed Forms 1-5. If you have any questions, please contact your Care Manager.

Cord Blood Bank of Canada :: 7030 Woodbine Avenue, #500 Markham, Ontario L3R 6G2 ::(905) 943-4933 EST