Request for an Information Kit

Please fill out this simple form to receive Cord Blood Banking Information. All information you provide is completely confidential.

Click on the following links to read about:
Form 1 - Client Service Agreement
Form 2 - Informed Consent for Collection and Storage of Cord Blood and collection and testing of Maternal Blood Sample
Form 3 - Limitation of Liability and Release
Form 4 - Authorization for Release of Information

* = Required Fields
* First Name: * Last Name:
* Address:   Address 2:
* City: * State/Province:
* Zip/Postal Code:
* Phone: * E-mail:
* Expected due date:
Promotion/Discount Code:
* How did you hear about the Cord Blood Bank of Canada?
If you have specific questions/comments you wish to have addressed, please enter them below.
Which of the following best describes you?
I am not very knowledgeable about cord blood banking but am interested in receiving more information.
I have researched cord blood banking but have not yet made a decision to bank.
I have decided to bank my baby's cord blood and would like more details about the Cord Blood Bank of Canada's services.
I want to enroll with the Cord Blood Bank of Canada. Please have a care manager call me. The best time to contact me is:
How did you become interested in the Cord Blood Bank of Canada?

It was recommended to me by my physician/midwife.
I heard about cord blood banking in pregnancy literature/friends and found you on the internet.
I am interested in emerging therapies that involve the use of cord blood stem cells (Parkinson's, Alzheimer's, spinal cord injuries, heart repair, diabetes, stroke).
I have a family history of a disease that is treatable with cord blood stem cells.
Other.
Did your physician or midwife discuss the benefits of saving your baby's cord blood? Yes
No
 
Cord Blood Bank of Canada :: 7030 Woodbine Avenue, #500 Markham, Ontario L3R 6G2 ::(905) 943-4933 EST
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