CryoLife

Application for Service of CRYOLIFE Family Cord Blood Bank provided by Cell Therapy Technologies Centre Limited

Please complete this registration form in English and in block letters

Personal Details of Expectant Mother

Full Legal Name Surname Please input the surname. Given Names Please input the given names. Full Name in ChinesePlease input the chinese name. ID Card No. / Passport No.Please choose the ID type.Please input the ID card no. or passport number.

NationalityPlease input the nationality. LanguagePlease choose the language.Please specify the language. Cantonese Putonghua English Others

Date of BirthPlease input a valid date of birth.Please input a valid date of birth.Please input a valid date of birth. DD MM YYYY OccupationPlease input the occupation.

Residential AddressPlease input the residential address. Correspondence Address (If different from the left)Please input the correspondence address.

Home Tel No.Please input the home telephone number. Office Tel No.Please input the office telephone number. Fax No.Please input the fax number.

Mobile Phone No.Please input the mobile phone number. Number of child (including this newborn)Please input the number of child. Natural Birth / Caesarean SectionPlease choose the method of giving birth. Natural Birth Caesarean Section

E-mail AddressPlease input the e-mail address. Expected Due DatePlease input the expected due date.Please input the expected due date.Please input the expected due date. DD MM YYYY

Personal Details of Expectant Father / Guardian Please choose the appropriate type.

Full Legal Name Surname Please input the surname. Given Names Please input the given names. Full Name in ChinesePlease input the chinese name. ID Card No. / Passport No.Please choose the ID type.Please input the ID card no. or passport number.

NationalityPlease input the nationality. LanguagePlease choose the language.Please specify the language. Cantonese Putonghua English Others

Date of BirthPlease input a valid date of birth.Please input a valid date of birth.Please input a valid date of birth. DD MM YYYY OccupationPlease input the occupation.

Home Tel No.Please input the home telephone number. Office Tel No.Please input the office telephone number. Fax No.Please input the fax number.

Mobile Phone No.Please input the mobile phone number. E-mail AddressPlease input the e-mail address.

Consultant Obstetrician / Gynecologist Please choose the appropriate type.

Name of DoctorPlease input the name of doctor. Chinese Name of DoctorPlease input the chinese name of doctor.

The attending doctor who is responsible for the delivery of your baby. The attending doctor who is responsible for the collection of your baby's cord blood.

Details of Hospital

The hospital where the delivery of your baby will take place.

Name of HospitalPlease input the name of hospital. Chinese Name of HospitalPlease input the chinese name of hospital.

>> Go to next page for Medical Health History Form

<< Go back Expectant Mother's Name Doctor's Name

HIV/AIDS, Hepatitis, Syphilis, Malaria and other diseases may be transmitted by infected cord blood samples. A negative HIV antibodies screening test result is a prerequisite for your enrolment. Cell Therapy Technologies Centre Limited must be informed of any history which may make Expectant Mother potentially infected by or become a carrier of any disease which might then infect the cord blood sample. This Medical Health History is therefore essential for checking whether the cord blood sample to be collected is potentially "at-risk".

Please check in the following appropriate boxes.

Expectant Father# Expectant Mother Yes No Yes No

Have Expectant Mother ever

1. Had any complications with this pregnancy?Please answer this question. 2. Had fresh vaginal bleeding for more than one day?Please answer this question. 3. Had vaginal infection or abnormal vaginal discharge? If yes, has it been cured? Yes / No Please answer this question.As you answered "Yes", please answer this follow-up question too. 4. Recent immunization / vaccination? If yes, please specify Please answer this question.As you answered "Yes", please specify. 5. From 1980 to 1996, had traveled/stayed in U.K. for more than 3 months?Please answer this question. 6. From 1980 to present, had stayed in any European country added up to more than 5 years? If yes, please specify Please answer this question.As you answered "Yes", please specify. 7. Had traveled/stayed in Africa?Please answer this question.

Have Expectant Mother or Expectant Father ever

8. Had a blood transfusion? If yes, when and which country Please answer this question.Please answer this question.As you answered "Yes", please state when and which country. 9. Been turned down as a blood donor? If yes, why? Please answer this question.Please answer this question.As you answered "Yes", please state why. 10. Had any body piercing, a tattoo or an accidental needle prick?Please answer this question.Please answer this question. 11. Been an intravenous drug user?Please answer this question.Please answer this question. 12. Been tested positive for Hepatitis B and/or C?Please answer this question.Please answer this question. 13. Had Malaria, Venereal Diseases, AIDS (or family members)?Please answer this question.Please answer this question. 14. Been in a malarial epidemic country?Please answer this question.Please answer this question. 15. Had Chagas' disease, babesiosis?Please answer this question.Please answer this question. 16. Had a serious illness e.g. cancer, leukemia, lymphoma?Please answer this question.Please answer this question. 17. Received human pituitary growth hormone before 1986?Please answer this question.Please answer this question. 18. Taken clotting factors for treatment of a bleeding disorder?Please answer this question.Please answer this question. 19. Had an organ/tissue/bone marrow transplantation, dura mater graft? If yes, please specify Please answer this question.Please answer this question.As you answered "Yes", please specify.

Had anyone in maternal or paternal family ever had

20. Fanconi's anemia, sickle cell anemia?Please answer this question.Please answer this question. 21. Chronic granulomatosis?Please answer this question.Please answer this question. 22. Thalassaemia, G6PD deficiency?Please answer this question.Please answer this question. 23. Immunodeficiency syndromes?Please answer this question.Please answer this question. 24. Degenerative diseases of the nervous system?Please answer this question.Please answer this question. 25. Creutzfeldt-Jakob Disease (CJD)?Please answer this question.Please answer this question.

# This part should be filled by Expectant Father

This Medical Health History shall be written in English and may be translated into other languages. In the event if any discrepancy between the English version and a translated version, the English version shall prevail.