CryoSave South Africa |

Client registration application

- Step 1 of 8

A. Client Particulars

Please complete this form electronically and submit to info@cryosave.co.za. Please contact +27 87 808 0170 or your consultant with any queries on completing this form.

1. Client 1/Mother/Legal Guardian

Last name *

First name

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

ID/Passport no *

Take Photo / Upload a copy of your ID *

Click or drag a file to this area to upload.

2. Client 2/Father/Partner

Last name *

First name

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

ID/Passport no *

Take Photo / Upload a copy of your ID Client 2

Click or drag a file to this area to upload.

3. Client 3/Child

Name and Surname (if known)

Due Date

Gender (if known)

Male
Female

Birth Type *

Natural
C-section

Births

Adoption
Surrogacy

4. Clinic/Hospital and Healthcare Practitioner (HCP)

Clinic/Hospital Name

Doctor/Midwife Name *

Tel No Clinic/Hosp

Doctor/Midwife Tel No *

HCP E-mail address

Where did you hear about CryoSave? *

Antenatal class
Healthcare Practitioner
EXPO
Brochure
Advert/Article
Previous storage
Referral
Other

Who referred you to CryoSave?

If "Other" please specify

5. Collection Kit Courier Details (physical address detail for delivery of the kit)

Contact Name *

Company Name (if applicable)

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone Number or Cell *

Alternative Phone Number

E-mail address *

Any special instructions?

B. Storage and Payment Options

6. Storage Options:

Please choose the relevant option:

Local storage (Umbilical Cord Blood & Umbilical Cord Tissue)
International Storage (Umbilical Cord Blood & Umbilical Cord Tissue)
Dual Storage (Umbilical Cord Blood & Umbilical Cord Tissue)

7. Payment Options:

I hereby accept the official quote as sent to me by CryoSave

Please choose the relevant payment option:

7.1 Once-off payment

Amount

A. EFT PAYMENT Banking details Account name: CryoSave South Africa (Pty) Ltd Bank: FNB Menlyn Square Account no: 62320699921 Branch code: 252 445 Reference: Use Client 1/mothers full name as reference
B. CREDIT CARD PAYMENT - For secure payment, enquire with your CryoSave Consultant Tel: 087 8080 170

7.2 Payment Plan

Amount

C. Medical History

Please answer the following questions at the time of registration to the best of your knowledge. This information will be treated confidentially and will be used by CryoSave to assess the suitability of the cord blood for storage and potential transplantation.

*Please note that you will be required to complete an additional short medical questionnaire at the time of your baby’s birth.

Medical History of the Biological Mother

1. Are you generally in good health? *

Please specify *

2. Are you currently taking any prescription medication? *

Please specify *

3. Were you diagnosed with a severe bacterial infection during your pregnancy? *

Please specify *

4. Have you, or your sex partner, ever had one of the following infections: Hepatitis B or C, HIV, Syphilis, HTLV I or II, West Nile, Zika, Ebola Virus, COVID-19, or other infectious diseases? *

Please specify *

5. Have you, or your sex partner, ever had a sexually transmitted infection? *

Please specify *

6. Did you, or your sex partner, receive a blood transfusion within the last 12 months? *

Please specify *

7. To the best of your knowledge, have you or your partner engaged in any activity which may have placed you at increased risk for a transmissible infection (e.g. HIV), or have you or your partner come into contact with someone else’s blood or body fluids (e.g. accidental needle stick injury, tattoo etc.)? *

Please specify *

8. Did you, or your partner, travel outside South Africa within the last 12 months? *

Please specify *

9. Have you ever been diagnosed with malaria? *

Please specify *

10. Have you travelled to, or resided in, a malaria area within the last 12 months? *

11. Were you in contact with a rabid animal? *

12. Have you ever stayed in a rural area of South America or been diagnosed with Chagas disease? *

13. Regarding Creutzfeldt-Jacob disease (CJD/TSE). Have you ever received a tissue or organ transplant? *

Please specify *

14. Were you vaccinated in the past 12 months (did you receive, for example, a vaccine for rabies, rubella, smallpox or hepatitis B)? *

Please specify *

15. To the best of your knowledge, have you, your baby’s father, or anyone in either family been diagnosed with: Sickle cell anaemia, thalassemia, Fanconi anaemia or other blood disorder, A genetic disorder, Diabetes, Autoimmune disorder? *

Please specify *

16. Are there any other medical disorders or risk factors that you consider may be relevant to the banking of your baby’s umbilical cord blood and/or cord tissue?

If you answered YES to any of the above questions, please provide details

I confirm that I have answered the above questions truthfully and to the best of my knowledge.

I provide Informed consent for maternal blood collection.

I provide Informed consent for collection, transport, processing, testing and storage of umbilical cord blood and tissue.

I provide Informed consent for data use.

Client registration application

A. Client Particulars

1. Client 1/Mother/Legal Guardian

2. Client 2/Father/Partner

3. Client 3/Child

4. Clinic/Hospital and Healthcare Practitioner (HCP)

5. Collection Kit Courier Details (physical address detail for delivery of the kit)

B. Storage and Payment Options

6. Storage Options:

7. Payment Options:

C. Medical History

Medical History of the Biological Mother

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