A GLOBAL REGENERATIVE THERAPEUTICS COMPANY
"The Safest and the most Secured Bank to preserve your baby's precious Cord Blood!"
UID NUMBER _______________
AGREEMENT NUMBER _______________
We congratulate and appreciate for your decision to preserve your baby's precious Cord Blood Stem Cells with StemCyte, India's only Global Hybrid (Private + Public) Cord Blood Bank!
We strive to provide best-in-class Cord Blood Banking & Services globally!
Thousands of expectant parents, just like you, are now choosing to privately bank their newborns' Umbilical Cord Blood to preserve Stem Cells for futuristic use. At StemCyte India, we are committed to offer you and your family a unique service to privately store your child's Umbilical Cord Blood and also offer extended support from our Public Bank. StemCyte India has a state-of-the-art processing facility that follows the same standardized procedures and quality controls as the parent company-StemCyte Inc., USA, that has earned the trust of parents and doctors around the world!
Preserving these precious Stem Cells guarantees an immediate availability of a perfect match for your child, should it be needed for treatment in future. These unique Stem Cells also improve the odds of having proper match for any other immediate family member, if needed.
Wishing you all the best and thanking you!
StemCyte India Team
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 02
-
Cord Blood Collection and banking is a 'once-in-a-lifetime' opportunity.
-
Once you have enrolled with StemCyte India for this service, please keep your Obstetrician/Gynecologist informed about the decision.
-
Notify StemCyte India's representative/nurse when you are going to the hospital and getting admitted for delivery.
-
This allows StemCyte India sufficient time to arrange for a collection nurse/assistant.
-
Follow the instructions as on Collection Kit Box and carry Collection Kit given by StemCyte India to hospital at the time of child's birth.
-
Mother's blood (i.e. both Biological Mother and/or Surrogate Mother) need to be collected before or after 7 (seven) days of Child's birth. If, for any reason the Mother's blood has not been collected or a repeat collection is required by StemCyte India, we request you to cooperate and allow for a repeat collection of blood sample. Please note that the tests done on maternal blood are important for storing your child's Cord Blood. A small volume would also be stored for future testing.
-
There will be a screening process in health history declaration to determine the eligibility of donor. Complete honesty in answering all the questions is very important. All information is confidential.
-
A Unique Numeric and Alphanumeric Identifier (UID) is generated against your Enrolment. This UID will be a link between you (as client) and the stored Cord Blood (CB) Unit.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 03
Parent's Full Name :- _________________________________________________________________________
Who's personal and residing address are set out in the Client Information Form (individually and collectively, the "Client") and
A company, incorporated under the Companies Act, 1956 and having its registered office at Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. This agreement outlines the rights and obligations of the parents as set forth in this document and is legally binding on the undersigned individual/s as Client and StemCyte India Therapeutics Pvt. Ltd.
'SCITPL' : StemCyte India Therapeutics Pvt. Ltd.
'Child' : The Client's Child from whom the Umbilical Cord Blood (UCB) is collected and stored.
'Client' : The parent/legal guardian of the Child or the Child herself/himself after the age of 18 (eighteen) years.
'Agreement' : Includes General Information, Service Agreement, Informed Consent, Release from Liabilities, Annexures, Client Information, Health History and Plan Particulars.
'Unit' : Cord Blood (CB) Unit - the nucleated cells including stem cells and hematopoietic progenitor cells harvested from placental and umbilical cord blood vessels from a single placenta after the umbilical cord has been clamped and cryopreserved using StemCyte's proprietary Plasma Depletion (PD) technology which can store up to 75 ml. The final stored volume, TNC Count, CD34+ Cells, CD34+ Cells viability etc. are subject to collected Cord Blood Unit.
'SCITPL Facility' : The processing laboratory and storage facility of SCITPL where the unit is processed, tested, and cryopreserved.
'HLA' : Human Leukocyte Antigen expressing the Histocompatibility in humans.
'Collection Kit' : The insulated container consisting of all necessary materials and instructions provided by SCITPL for the purpose of collection of single Cord Blood (CB) Unit and maternal blood sample.
'Service' : Collective process of collection, processing, testing, cryopreservation and retrieval of Cord Blood Unit.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 04
'Notification' : The action of notifying the Client for unsuitability of their collected cord blood sample with intention of seeking their involvement.
'StemCyte Public Bank' : A program where StemCyte takes donations of Cord Blood from donors for storage which meets or exceeds the Public Banking Guidelines set by regulatory bodies or accrediting agencies, intended to be used by unrelated patients.
'Stem Cell transplant / Approved Transplant' : The administration of Cord Blood (CB) Cells with the intent of providing transient or permanent engraftment in support of therapy for any approved hematopoietic indications / diseases as per Indian Regulatory Authority / National Guidelines for Stem Cell Research by ICMR and DBT; diagnosed after the Unit has been stored.
Note: If treatment is approved by country where treatments is being taken will this be covered
As per the plan opted by the client and as per the terms of this agreement, if the client require a Unit from StemCyte Public Bank for an Approved Transplant, then the client shall get a highest HLA matched unit at no extra cost from SCITPL's Public Bank inventory and if such unit is not found then SCITPL shall extend the support to get Unit from its global inventories located in USA and Taiwan at no extra cost.
'Approved Clinical Trial' : Any clinical trial approved by the regulatory body in the country where the Clinical Trial is performed.
As per the plan opted by the client and as per the terms of this agreement, if the client require a Unit from StemCyte Public Bank for an Approved Clinical Trial, then the client shall get a highest HLA matched unit at no extra cost from SCITPL's Public Bank inventory.
Upon enrolment and receipt of appropriate fees and charges SCITPL will:
3.1. Provide a Collection Kit.
3.2. Organize collection and shipment of the Unit (refer clause no. 5).
3.3. Process and cryopreserve the Unit, subject to the terms and condition of this Agreement.
3.4. Perform tests on the Unit as mentioned in Annexure I.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 05
In order to receive this Service, Client agrees to:
4.1. Review, complete, sign and return: (I) General Information, (II) Service Agreement, (III) Informed Consent, (IV) Release from Liabilities, (V) Annexures (VI) Client Information (VII) Health History (VIII) Plan Particulars.
4.2. Handover all payment instruments to SCITPL before the Unit reaches SCITPL's facility for final cryopreservation.
4.3. Inform SCITPL of any change of address and contact information or any other information during the tenure of this agreement.
4.4. When the Collection Kit is handed over, store as per instruction given in the Collection Kit.
4.5. Carry the Collection Kit to the birthing hospital and hand it over to the Delivering doctor or dedicated paramedic staff.
4.6. Notify SCITPL or its representative for collection of the Unit as described in clause no. 5.
5.1. Upon payment of applicable fees by the Client, SCITPL will make arrangements to send trained and skilled technician or nurse for collection of the Unit and maternal sample at the time of delivery, provided that prior intimation to SCITPL is given at least 3 hours before child's birth. If the birthing center is in a remote area and/or in case of any emergency, Gynecologist / Obstetrician / OT Assistant shall help in the collection of Cord Blood, provided SCITPL is given sufficient time for co-ordination and detailed explanations about procedure to the concerned person.
5.2. The said skilled technician/nurse/doctor shall be responsible for appropriate labelling and packaging of the Unit and also will instruct the courier agency for pickup and X-Ray free shipment to SCITPL's facility.
This Agreement shall commence from the date of birth of the child and shall be in force as per the plan chosen by the client. The term of the agreement and the term of the benefits available to the client are as under the "Annexure II" of this agreement.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 06
7.1. The Client is the custodian of the Unit until the Child attains the age of 18 (eighteen) years.
7.2. On the Child's 18th (eighteenth) birthday, he/she will become the owner of the Unit.
7.3. If there is any disagreement between the parents during the first 18 (eighteen) years, then the mother's wish shall prevail.
7.4. In the event of sad demise of the Client, the legally authorized guardian becomes the custodian of the Unit until Child attains 18 (eighteen) years. In a case where Child who becomes owner at the age of 18 (eighteen) dies after that, then legal heirs become the custodian of the Unit.
8.1. Neither SCITPL nor any affiliate will release any identifiable health information unless such disclosure is authorized by the Client or required by the law.
8.2. Pursuant to the laws applicable to SCITPL, SCITPL may be required to provide the FDA or other Indian government or accrediting agencies with access to the Client's health information. Also, the law requires SCITPL to notify local or state health agencies of confirmed positive test results for certain diseases
SCITPL understands the various possibilities under which multiple benefits are required for a client to help facilitate a stem cell transplant. SCITPL with its expertise have designed multiple benefits under its "StemCyte Salient Features" that are unmatched in the industry. These are applicable as per the plan chosen by the Client and are detailed under the "Annexure II" of this agreement, subject to all payment being received as per plan chosen by the client.
SCITPL shall notify to the client at least 90 (ninety) days before the term of this agreement. The agreement can be renewed at the end of the plan term, as per then prevailing terms and conditions by paying the applicable fees.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 07
11.1. SCITPL is liable to release the Unit for approved transplant or approved clinical trial during the tenure of this Agreement subject to all payments received as per the plan.
11.2. In the event the Unit is required for an appropriately planned approved transplant procedure or approved clinical trial, SCITPL will release the Unit upon receiving the transplant physician's written request confirming the end use. On performing all the required quality tests on the Unit, it will be ready for shipment in maximum 21 (twenty-one) days from receipt of the request. All the cost incurred towards necessary tests and shipment will be borne by SCITPL; as per the terms of the agreement. The then prevailing National / International Standards and Government regulations will be followed for shipment of the Unit.
Any installment facility provided to the Client for the fee and cost already covered by SCITPL shall cease to exist on such termination and SCITPL shall claim the entire fee, from the Client which if not paid will be recoverable through process of law. Under any circumstances or scenario Client would not be entitled to claim any other amount by any means apart from the payment he/she has paid. Upon receiving required documents and verification, any refund shall be done within 30 business days.
If there is a default/deferral in payment on the part of the Client, then the Client will be notified for the payment interruption for maximum 3 (three) notices.
If the said due amount is not paid within the timeline as mentioned in the notice by SCITPL, the Client agrees that the account is in default, and the entire balance on the account is due and payable immediately. If the Client fails to discharge payment obligation, then SCITPL permitted to use or dispose of the Client's Unit and in this case, Agreement would stand terminated.
The Client can terminate the Agreement only prior to the Child's birth. SCITPL shall retain registration fees and refund the rest if paid in advance.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 08
In the event, the prevailing law or government regulations require terminating the Agreement, then the Agreement stands Terminated within 30 (thirty) days. SCITPL shall refund storage fees on pro rata basis.
The Agreement shall be terminated at the end of the term of the plan if not renewed as per clause no.10.
12.5.1. Non-collection / Loss of Cord Blood Unit: The Client understands that delivery of the baby cannot be always planned. Cord Blood collection may be missed due to multiple circumstances not limited to situations where SCITPL is not provided with prior intimation on delivery timing/place of delivery, or not given adequate time to make arrangements or the Client forgets or fails to handover the Collection Kit within a reasonable period of time to SCITPL assigned phlebotomist or the hospital staff. In such an event, SCITPL shall not be held liable for its actions or omissions and the Agreement shall stand terminated. If the cord blood collection opportunity is lost due to service gap from SCITPL, SCITPL shall refund the entire fees if already paid in advance after necessary verification and documentation.
12.5.2. Unavailability / Unsuitability of Cord Blood Unit for processing: In the unlikely event that the Unit is lost during transit from collection center to laboratory, damaged or cannot be processed for any reason, SCITPL shall promptly notify the Client. The Cord Blood Unit, if collected shall be discarded with prior notice if there is an inadequate volume of Cord Blood collected i.e., below 08 ml, SCITPL reserves the right not to process and consequently discard the Cord Blood Unit. In such incidences, the client will be given an option to continue the agreement by providing one Unit from StemCyte Public Bank subject to full payment being received or terminate the agreement. In case of termination, SCITPL shall retain the enrolment fees and refund the rest if already paid in advance.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 09
Under any circumstances or scenario Client would not be entitled to claim any other amount by any means apart from the payment he/she has paid.
12.5.3. Unsuitability of Stem Cells for cryogenic preservation: If the processed cold blood unit is defined unfit for cryo-preservation as per international and national guidelines and SOPs followed by SCITPL, SCITPL shall provide possible options to further continue the agreement to the client within scope of service. If not so, with mutual consent between client and SCITPL, the agreement shall be terminated & the unit shall be discarded. SCITPL shall refund the storage fee and retain the rest.
12.5.4. Non-disclosure of maternal information in Health History Questionnaire: SCITPL reserves the right to terminate the Agreement if any information provided in the Health History Questionnaire is false and/or the Client has intentionally withheld material information. In such cases there will be no refund of fee paid. SCITPL will not be liable to honor any commitments mentioned in the Agreement in case it is found that wrong information is been provided or else material information is not disclosed.
In the event that the Child's Cord Blood Unit is retrieved and all the benefits based on the plan opted by the client as mentioned under "StemCyte Salient Features" are fully utilized by the Client including Additional Unit / Multiple Additional Units, Safeguard Program and Life Saver Guarantee; then the agreement shall be terminated automatically and the same shall be notified to the Client.
Serving of Notification to be sent under this Agreement to client shall be sufficiently (deemed to be) given when delivered by registered electronic mail ID (E-mail ID) as provided in the Agreement.
The Client understands that SCITPL will make its best efforts to store the Unit for the term of Agreement; but, in the event that SCITPL is unable to provide continued storage
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 10
during the term of this Agreement, the Client may continue to store the Unit at a bank contracted at that time by SCITPL at the pro rata cost for the remaining period, to be paid by SCITPL. Or, the Client may choose to, at his/her own risk and expense, arrange for the transfer of the stored Unit to another facility. In such a case the Client will release SCITPL of all the responsibilities and the Agreement would stand terminated.
Note: No claim, until requirement is confirmed
In the event when Force Majeure has occurred, including without limitation to natural disasters, fires, strikes, terrorist act, war etc. and if there is loss or damage of unit including in transit from storage facility to transplant center and Child or Sibling or Parent or Grandparent (Maternal and Paternal) is diagnosed for any conditions approved by regulatory authority, SCITPL shall provide one highest HLA matched Unit from StemCyte Public Bank free for Stem Cell Transplant. If SCITPL cannot find one Unit from StemCyte Public Bank inventory, then SCITPL agrees to pay up to ₹ 20,00,000/- (Rupees Twenty Lakhs only) to find and purchase a suitably matched Unit through worldwide registries.
In the event any Cord Blood Unit provided by SCITPL is required for an approved transplant or approved clinical trial then SCITPL shall arrange for the transport to a transplant center anywhere in the world at no extra cost.
This Agreement shall be governed by, construed and interpreted in accordance with the Indian laws. The Courts/Forum at Gandhinagar, Gujarat, India; alone shall have the exclusive jurisdiction over any dispute / claim arising out of this Agreement.
Any changes to this Agreement must be in writing and signed by the party or parties to this Agreement and SCITPL, in order to be enforceable.
19.1. Any notice to be given under this Agreement shall be sufficiently given if delivered in person or sent by electronic mail or by registered or certified mail. Notice to
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 11
SCITPL shall be addressed to the COO and delivered at SCITPL's registered address at StemCyte India Therapeutics Pvt. Ltd., Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428.
19.2. Notice to the Client shall be delivered to the address provided in the Agreement or subsequent address as the Client may provide to SCITPL. Such notice shall be deemed to have been given on the date so personally delivered or received by mail or electronic mail or after expiry of 24 hours of its posting by SCITPL by registered post.
All covenants and agreements made in this Agreement that, by their terms, require performance after the termination of this Agreement, shall survive the termination of this Agreement.
21.1. SCITPL may assign this Agreement to any individual, association, partnership or corporation that is either providing a similar service or intends (subsequent to such assignment) to provide a similar Service.
21.2. If SCITPL is acquired by or merged with or into another company, as a condition of such merger or acquisition, SCITPL shall require that the terms of this Agreement continue in full force and effect.
All of the obligations, terms, provisions and releases set forth in this Agreement shall be binding upon and inure to the benefit of SCITPL and the Client, as well as to each party's respective heirs, personal representatives, successors and assignees.
Note: What does this imply?
The Client agrees that the provisions of this Agreement are severable, and if any part of this Agreement is found to be invalid or unenforceable, this Agreement shall otherwise remain in full force and effect. The Client has been given an opportunity to ask questions about this Agreement and all the questions have been answered to satisfaction.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 12
The Client hereby certifies that all information that the Client has provided to SCITPL pursuant to the Agreement are true and accurate.
This Agreement, the Informed Consent to blood collection and testing, the authorization of use and disclosure of General Information, Service Agreement, Informed Consent, Release from Liabilities, Annexures, Client Information, Health History and Plan Particulars (collectively, the Agreement) constitute the full and entire understanding and Agreement between the Parties and are intended to be the final, complete and exclusive statement of the terms of the Agreement with regard to the subjects hereof and thereof. The Agreement supersede all other prior agreements, communications, and statements, whether written or verbal, expressed or implied, pertaining to that subject matter, may not be contradicted by evidence of any prior or contemporaneous statements or agreements, written or verbal, and may not be explained or supplemented by evidence of consistent additional terms. In case of conflict between any document and a term of this Agreement, this term of this Agreement shall prevail.
Neither SCITPL, their affiliates, successor, assigns, officers, directors, employees, agents, independent contractors or subcontractors have ever made any representations, guarantees or warrantees, express or implied, to the Client of any type or nature, including but without limiting the generality of the foregoing guarantees or warrantees with respect to:
I) Suitability of the Unit for future treatment of diseases.
II) Success of the stem cell transplantation procedure using the Unit.
III) Any advantage of the Unit for transplantation over other treatments.
IV) The merchantability or fitness for a particular purpose or use of any product or service hereunder.
Furthermore, though the Unit will be a perfect match for the Child, its probability of match with his/her sibling varies from 0-100 %, and is a likely match for the parents.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 13
It is important that you understand everything before you sign this document. If you have questions, you may contact SCITPL's office at the number listed below or, you may discuss issues or questions with family, friends or healthcare professionals who are in no way associated with this program before deciding whether or not to store your baby's cord blood.
Participating in the SCITPL Private Umbilical Cord Blood Banking Service is entirely voluntary. However, to participate in the Service, you will have to agree to have your baby's cord blood and a sample of your blood collected at the time of birth and tested for certain diseases to determine if the cord blood is appropriate for storage. This form provides information regarding these procedures, including associated risk and benefits. After reviewing the information below, please sign this informed consent for Blood Collection and Testing, if you agree to the collection and testing of your baby's cord blood and a sample of your blood, as further described below. Please keep a copy of this informed consent for your records. The procedure and blood test described in this informed consent are required in order to participate in the service.
Collection of the cord blood will only happen after the delivery of your baby, clamping and cutting of the umbilical cord, and separating the baby from your body. Because you and your baby are physically separated before the cord blood is taken, cord blood collection should not pose a risk to you or your child. However, cord blood will not be collected if your healthcare professional believes that the collection might pose a potential harm to you or your child - for example if there are complications during delivery or if the delivery is too early. SCITPL relies on the recommendation of your health care professional and does not participate in any medical decision-making related to the cord blood collection. Taking blood from your arm for testing may involve discomfort, pain, bruising, infection, and fainting. As required by applicable law you will be informed of any infectious disease test result that may pose a threat to you or your baby. If you test positive for an infectious disease, you should consult your physician about the possibility of breast feeding and also may be asked not to donate whole blood in the future. You will be informed of positive results that show the presence of conditions that may cause health risk. This may cause you to have to deal with health concerns, which may or may not occur in the future.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 14
Test that detects infectious disease, such as exposure to HIV, Hepatitis B, Hepatitis C, Syphilis or Malarial Parasite may provide important information that may require you to seek prompt attention from your healthcare provider.
If an initial HIV test is positive, we will perform a second confirmatory test. If, and only if, the confirmatory test is positive, we will conclude that you have been exposed to HIV. However, irrespective of whether you test positive on only the screening or both screening and confirmatory test, your child's cord blood cannot be stored at SCITPL. Testing positive for HIV does not mean that you have AIDS. If you test positive, you should seek advice from your healthcare provider. Also, you may wish to seek assistance from local AIDS organization.
I, the undersigned, has reviewed and understood in the language best known to me, the above information regarding possible risks of having samples of my blood collected (as per SCITPL's requirement) and tested for certain diseases. I wish to participate in the Service provided by SCITPL and hereby give consent to the following procedures:
-
I agree to allow my doctor to collect my baby's cord blood at the time of birth of my child, and to draw a sample of my blood within 7 (seven) days of the birth of my baby.
-
I agree to allow the staff to review the hospital medical charts of me and my baby during my hospitalization for this pregnancy in order to evaluate the suitability of the cord blood. This includes permission to check my prenatal test results and medical history including testing for HIV I & II (the virus that causes AIDS), HCV, HBV, CMV, HTLV I / II, Syphilis, Malaria.
-
A link will be maintained at SCITPL between me, my infant, and the cord blood unit in order to allow SCITPL to inform me of any positive test results and how they may affect my health or my baby's health or to contact me directly in the future. I will be offered a counseling referral, if needed.
-
I agree to allow program personnel to contact me in the future regarding my baby's health. Because some signs and symptoms of inherited conditions do not appear or may not be detected until a certain period of time after birth, SCITPL may contact me 6 (six) to 12 (twelve) months after the birth of my child by telephone or by sending me a letter containing follow up questions related to inherited diseases and conditions.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 15
-
I may also be contacted at a later date by telephone / mail if required.
-
I agree that the cord blood unit can be used for my immediate family members only.
-
If for any reasons, any terms of the agreements are not followed by me, then I agree to allow that SCITPL can use my umbilical cord blood unit for patients in need / clinical trials and SCITPL shall inform me about the retrieval of the cord blood unit.
I agree SCITPL to arrange for my blood sample tested for certain infectious diseases, in order to determine whether the cord blood is suitable for storage.
-
In specific, tests as follow: - HIV (The virus that causes AIDS), Hepatitis B and Hepatitis C Viruses, Syphilis, Malaria, Human T-Lymphotropic Virus (HTLV I / II), Cytomegalovirus (CMV) and other required tests.
-
I agree to SCITPL to arrange my baby's cord blood tested for the Red Blood Cell type (ABO Rh), Cell Viability, Total Nucleated Cells, Sterility and other selected tests in order to evaluate the suitability and identity of the cord blood for storage and/or transplantation.
-
I realize that some testing may be performed at the time of transplant.
-
I agree to get the service of SCITPL for processing and storage of my baby's Cord Blood.
Please feel free to contact SCITPL's office. If you have any questions, we have trained personnel to answer all of your questions and to discuss your concerns.
I understand that the results of all the tests performed on the cord blood and my blood are confidential and can be disclosed only as authorized by me or as required by Governing Law or accrediting agencies. I also understand that SCITPL will be bound to report to local Governing bodies about any positive test result for HIV I & II. I also understand that my Obstetrician/Gynecologist will also be notified about the same.
Note: Family member must not serve as an interpreters or translators.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 16
यह महत्वपूर्ण है कि आप इस दस्तावेज पर हस्ताक्षर करने से पहले सब कुछ समझ ले। याद आपके कोई प्रश्न हैं, तो आप नीचे सूचीबद्ध नंबर पर SCITPL के कार्यालय से संपर्क कर सकते हैं, और/या हस्ताक्षर करने से पहले कि आपके बच्चे के गर्भनाल रक्त को संग्रह करना है या नहीं, ये आप अपने परिवार, दोस्तों या स्वास्थ्य संबंधी पेशेवरों के साथ मुद्दों या प्रश्नों पर चर्चा कर सकते हैं जो इस कार्यक्रम से पहले कभी भी जुड़े नहीं हैं।
SCITPL प्राइवेट अम्बिलिकल कोर्ड ब्लडिंग सर्विस में भाग लेना पूर्णत: स्वैच्छिक है. हालाँकि, सेवा में भाग लेने के लिए, आपको अपने बच्चे के गर्भनाल रक्त और जन्म के समय एकत्रित आपके रक्त का एक नमूना लेने के लिए सहमत होना होगा और यह निर्धारित करने के लिए कुछ बीमारियों का परीक्षण करना होगा कि क्या गर्भनाल रक्त संग्रह के लिए उपयुक्त है? वह फॉर्म इन प्रक्रियाओं से संबंधित जोखिम और लाभों सहित जानकारी प्रदान करता है। यदि आप अपने बच्चे के गर्भनाल रक्त एवं आपका रक्त लेने और परीक्षण के लिए सहमत हैं, जैसा कि नीचे वर्णित है तो नीचे दी गई जानकारी की समीक्षा करने के बाद कृपया सूचित सहमति पर हस्ताक्षर करें। कृपया अपने रिकॉर्ड के लिए इस सूचित सहमति की एक प्रति रखें।
गर्भनाल रक्त केवल आपके बच्चे की डिलीवरी, गर्भनाल की क्लैम्पिंग और कर्टिंग के बाद, और आपके शरीर से बच्चे को अलग करने के बाद ही लिया जाएगा क्योंकि कॉर्ड ब्लड लेने से पहले आप और आपका बच्चा शारीरिक रूप से अलग हो जाते हैं, कॉर्ड ब्लड कलेक्शन से आपको या आपके बच्चे को कोई खतरा नहीं होगा. हालाँकि, यदि आपके स्वास्थ्य सेवा पेशेवर का मानना है कि संग्रह आपके या आपके बच्चे के लिए संभावित नुकसान का कारण बन सकता है, तो गर्भनाल रक्त एकत्र नहीं किया जाएगा - उदाहरण के लिए यदि प्रसव के दौरान जटिलताएं हैं या गर्भ के बाद एक निश्चित उम्र तक पता नहीं लगाया जा सकता है, SCITPL आपके स्वास्थ्य देखभाल पेशेवर की सिफारिश पर निर्भर करता है और गर्भनाल रक्त संग्रह से संबंधित किसी भी चिकित्सा निर्णय लेने में भाग नहीं लेता है।
परीक्षण के लिए अपने हाथ से रक्त लेने से असुविधा, दर्द, चोट, संक्रमण और बेहोशी हो सकती है। जैसे कि लागू कानून द्वारा आवश्यक है, आपको किसी भी संक्रामक रोग परीक्षण के परिणाम से अवगत कराया जाएगा जो आपके या आपके बच्चे के लिए खतरा पैदा कर सकता है। यदि आपका परीक्षण परिणाम एक संक्रामक बीमारी के लिए सकारात्मक रिपोर्ट देखता है तो आपको स्तनपान की संभावना के बारे में अपने डॉक्टर से परामर्श करना चाहिए और भविष्य में आपको रक्त दान करने के लिए मना किया जा सकता है। आपको सकारात्मक परिणामों से अवगत कराया जाएगा जो उन स्थितियों की उपस्थिति दिखाते हैं जो स्वास्थ्य जोखिम का कारण बन सकती है। इससे आपको स्वास्थ्य संबंधी चिंताओं, जो भविष्य में हो भी सकती है और नहीं भी, से जूझना पड़ सकता है।
टेस्ट जो संक्रामक बीमारी का पता लगाता है जैसे HIV, Hepatitis B, Hepatitis C, Syphilis or Malaria , जो महत्वपूर्ण जानकारी प्रदान कर सकता है जिसके लिए आपको अपने स्वास्थ्य सेवा प्रदाता से तुरंत परामर्श करने की आवश्यकता हो सकती है।
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 17
यदि प्रारंभिक एचआईवी परीक्षण सकारात्मक है, तो हम एक दूसरी पुष्टिकर्णी परीक्षण करेंगे। यदि, और केवल यदि , पुष्टिकर्णी परीक्षण सकारात्मक है, तो हम निष्कर्ष निकालेंगे कि आप एचआईवी के संपर्क में हो लताऊँकि, इसके बावजूद कि आपका परीक्षण परिणाम केवल स्क्रीनिंग या स्क्रीनिंग और पुष्टिकरण परीक्षण दोनों के लिए सकारात्मक है, आपके बच्चे के गर्भनाल रक्त को SCITPL में संग्रहित नहीं किया जा सकता है। HIV के लिए सकारात्मक परीक्षण का मतलब यह नहीं है कि आपको AIDS है। यदि आपका परीक्षण परिणाम सकारात्मक है, तो आपको अपने स्वास्थ्य सेवा प्रदाता से सलाह लेनी चाहिए इसके अलावा, आप स्थानीय AIDS संगठन से भी सहायता ले सकते हैं।
मैं, असंदर्शित, मेरे लिए सबसे अच्छी तरह से जमाने वाली भाषा में मेरे रक्त के नमूने एकत्रित करने के संभावित जोखिम (SCITPL की आवश्यकता के अनुसार) और कुछ बीमारियों के लिए परीक्षण किया जाएगा। मैं SCITPL द्वारा प्रदान की गई सेवा में भाग लेना चाहता हूं और इसके बाद निम्नलिखित प्रक्रियाओं के लिए सहमति देता हूं:
-
मैं अपने डॉक्टर को अपने बच्चे के जन्म के समय अपने बच्चे के गर्भनाल रक्त को इकट्ठा करने की अनुमति देने के लिए और अपने बच्चे के जन्म के 7 दिनों के भीतर अपने रक्त का एक नमूना लेने के लिए सहमत हूं।
-
मैं इस गर्भस्था के लिए गर्भनाल रक्त की उपयुक्तता का मूल्यांकन करने के लिए अपने अस्पताल में भर्ती होने के दौरान मेरे और मेरे बच्चे के अस्पताल के मेडिकल चार्ट की समीक्षा करने की अनुमति देने के लिए सहमत हूं। इसमें मेरे prenatal परीक्षण के परिणाम और HIV I & II (एड्स का कारण बनने वाला वायरस), Hepatitis B, Hepatitis C, CMV, HTLV I/II, Syphilis and Malaria सहित परीक्षण की जांच करने की अनुमति शामिल है।
-
SCITPL में मेरे, मेरे शिशु और गर्भनाल रक्त यूनिट के बीच एक लिंक रखा जाएगा ताकि SCITPL मुझे किसी भी सकारात्मक परीक्षण के परिणाम की सूचना दे सके और जो मेरे स्वास्थ्य या मेरे बच्चे के स्वास्थ्य को प्रभाव कर सकें या भविष्य में सीधे मुझसे संपर्क कर सकेंगे। मुझे पर मुझे काउंसलिंग रेफ़रल की पेशकश की जाएगी।
-
मैं अपने बच्चे के स्वास्थ्य के संदर्भ में कार्यक्रम कर्मियों को भविष्य में मुझसे संपर्क करने की अनुमति देने के लिए सहमत हूं। क्योंकि जन्म के बाद की स्थिति के कुछ संकेत और लक्षण प्रकट नहीं होते हैं या जन्म के बाद एक निश्चित उम्र तक पता नहीं लगाया जा सकता है, SCITPL मेरे बच्चे के जन्म के 6 से 12 महीने बाद टेलीफोन द्वारा या एक पत्र भेजकर विरासत में मिली बीमारियों और स्थितियों से संबंधित प्रश्न कर सकता है। यदि आवश्यक हो तो मुझे टेलीफोन / मेल द्वारा बाद में भी संपर्क किया जा सकता है।
-
मैं सहमत हूं कि गर्भनाल रक्त यूनिट का उपयोग केवल मेरे नजदीकी परिवार के सदस्यों के लिए किया जा सकता है।
-
यदि किसी भी कारण से, समझौतों की किसी भी नियम का मेरे द्वारा पालन नहीं किया जाता है, तो मैं इस बात की अनुमति देने के लिए सहमत हूं कि SCITPL मेरी गर्भनाल रक्त यूनिट का उपयोग जरूरतमंदों की आवश्यकता के लिए / नैदानिक परीक्षणों में कर सकता है और SCITPL मुझे गर्भनाल रक्त यूनिट की रिट्रीवल के बारे में सूचित करेगा।
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 18
मैं सहमत हूं कि SCITPL कुछ संक्रामक रोगों के लिए मेरे रक्त के नमूने की व्यवस्था करेगा, ताकि यह निर्धारित किया जा सके कि क्या संग्रह के लिए गर्भनाल रक्त उपयुक्त है?
-
विशिष्ट में, परीक्षण निम्नानुसार हैं: -HIV (एड्स का कारण बनने वाला वायरस), Hepatitis B, Hepatitis C, Syphilis, Malaria, HTLV I / II (मानव टी-लिम्फोट्रोपिक वायरस), CMV और अन्य आवश्यक परीक्षणा।
-
मैं इस बात से सहमत हूं कि प्रत्यारोपण के लिए गर्भनाल रक्त की उपयुक्तता और पहचान का मूल्यांकन करने के लिए SCITPL मेरे बच्चे के Red Blood Cell type (ABO Rh), Cell Viability, Total Nucleated Cells, Sterility (शुद्धजीवित्वबाली परीक्षण) और अन्य तयनित परीक्षणों के लिए परीक्षण करेगा।
-
मैं इस बात से सहमत हूं कि प्रत्यारोपण के समय कुछ परीक्षण किए जा सकते हैं।
-
मैं अपने बच्चे की गर्भनाल रक्त यूनिट के प्रसंस्करण और संग्रह के लिए SCITPL की सेवा प्राप्त करने के लिए सहमत हूं।
कृपया SCITPL के कार्यालय से संपर्क करें। यदि आपके कोई प्रश्न हैं, तो हमने आपके सभी सवालों के जवाब देने और आपकी चिंताओं पर चर्चा करने के लिए कर्मियों को प्रशिक्षित किया है।
मैं समझता हूं कि गर्भनाल रक्त और मेरे रक्त पर किए गए सभी परीक्षणों के परिणाम गोपनीय हैं और केवल अधिकृत विधान की Acekal fepu olrot उन या शासकीय कानून या मान्यता देने वाली एजेंसियों की जरूरत पड़ने पर खुलासा किया जा सकता है। मैं यह भी समझता हूं कि SCITPL, HIV I & II के किसी भी परीक्षण के सकारात्मक परिणाम के बारे में स्थानीय शासकीय निकायों को रिपोर्ट करने के लिए बाध्य होगा। मैं यह भी समझता हूं कि मेरे प्रसूति / स्त्री रोग विशेषज्ञ को भी इस बारे में सूचित किया जाएगा।
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 19
આ દસ્તાવેજ ઉપર સહી કરતાં પહેલાં તમે બધું જ સમજો તે મહત્વપૂર્ણ છે. જો તમને કોઈ પ્રશ્ન હોય તો તમે નીચે સૂચિત્ધુમ નંબર ઉપર SCITPL-ની ઓફિસનો સંપર્ક કરી શકો છો, અથવા તમારા બાળકના કોર્ડ બ્લડને સ્ટોર કરવું કે નહીં તે નક્કી કરતાં પહેલાં તમે આ પ્રકીય સાથે કોઈ રીતે ન સંકળાયેલા કુટુંબીઓનો, મિત્રો કે હેલ્થકેર પ્રોફેશનલ સાથે પ્ર.શ્નો કે સમસ્યાઓની ચર્ચા કરી શકો છો.
SCITPL પ્રાઇવેટ અમ્બાઇલિકલ કોર્ડ બ્લડ બેંકિંગ સર્વિસમા ભાગ લેવો તે સંપૂર્ણ સ્વૈચ્છિક છે. જો કે આ પ્રકીયામા ભાગ લેવા માટે તમારે તમારા બાળકના કોર્ડ બ્લડ અને તમારા બ્લડનો નમુનો પ્રસુતિ સમયે કલેકટ કરવા અને ચોક્કસ પરીક્ષણ દ્વારા તમારા બાળકનું કોર્ડ બ્લડ સંગહ માટે યોગ્ય છે કે નહીં તે નિર્ધારીત કરવા સહમત થવું પડશે. આ ફોર્મ આ પ્રકીયાઓ અને તેઓની સાથે સંકળાયેલા લાભો અને જોખમો અંગેની માહિતી પ્રદાન કરે છે. જો તમે વધુમાં નીચે વર્ણવ્યા મુજબ તમારા બાળકના કોર્ડ બ્લડ અને તમારા બ્લડના નમુનાના કલેક્શન અને પરીક્ષણ માટે સહમત હો તો નીચે વર્ણવેલ માહિતીની સમીક્ષા કર્યા બાદ રકન સંગહ અને પરીક્ષણ માટે સૂચિત સંમતિ પર સહી કરો. કૃપા કરી આ સૂચિત સંમતિની એક કોપી તમારા રેકોર્ડ માટે તમારી પાસે રાખો. આ સેવામા ભાગ લેવા માટે સૂચિત સંમતિમાં વર્ણવેલ પ્રકીયાઓ અને રકત પરીક્ષણો જરૂરી છે.
કોર્ડ બ્લડ કલેક્શન તમારા બાળકના જન્મ, ગર્ભનાળનો ક્લેમ્પીંગ, કર્ટીંગ તેમજ તમારા બાળકને તમારા શરીરથી જુદા પાડ્યા બાદ જ કરવામાં આવશે. કોર્ડ બ્લડ કલેક્શન કરતું એ તમને કે તમારા બેબીને કોઈ જોખમ નહું પેંતાડે જ એવી છતા કે જ તેમ છતા કે કોર્ડ બ્લડ કલેક્શન તમારા કે તમારા બાળકને સંભવિત નુકસાન પહોચાડી શકે છે, દા.ત. ડીલીવરી દરમ્યાન કોમ્પલીકેશન હોય કે ડીલીવરી ખૂબ જલદી થાય તો કોર્ડ બ્લડ કલેક્શન કરવામાં આવશે નહીં.
SCITPL તમારા હેલ્થકેર પ્રોફેશનલની ભલામણ પર આધાર રાખે છે અને કોર્ડ બ્લડ કલેક્શન સંબંધિત કોઈપણ તબીબી નિર્ણયમા ભાગ લેતા નથી.પરીક્ષણ માટે તમારા હાથમાંથી રકત લેવાથી તમને અસ્વસ્થતા, પીડા, ઉઝરડા, ચેપ કે બેભાનતા આવી શકે છે. લાગુ પડતા કાયદા અનુસાર તમને કોઈપણ ચેપી રોગના પરિણામો પરિણામ વિશે આગમત રીતે જણાવ કરવામાં આવશે જે તમારા કે તમારા બાળક માટે જોખમ ઉભુ કરી શકે છે. જો તમારા પરીક્ષણ પરિણામ ચેપી રોગ માટે હકારાત્મક છે, તો તમારે તમારા ચિકિત્સકના સલ્હેબાર્સ્ટફિડિંગની સંભાવના વિશે સલાહ લેવી જોઈએ અને ભવિષ્યમા રકદદાન ન કરવા માટે પણ કરી શકાય. તમને આરોગ્યનું જોખમ લાવી શકે તેવી હકારાત્મક પરિણામોની જાણ કરવામાં આવશે. આનાથી તમને આરોગ્યની ચિંતાઓને પદસીંધી વાત્તુ પડી શકે છે, જે ભવિષ્યમાં થઈ શકે કે નહીં પણ.
ચેપી રોગ જેવા કે HIV, Hepatitis B, Hepatitis C, Syphilis, Malaria Parasite ના પરીક્ષણની માહિતી આપવામાં આવી શકે છે જેથી તમારે તમારા ડોકટરનું ધ્યાન તત્કાલ જ દોરવું પડે.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 20
જો પ્રારંભિક HIV પરીક્ષણ હકારાત્મક હશે, તો અમે બીજા પુષ્ટિકરક પરીક્ષણ કરીશું. જો અને ફક્ત જો પુષ્ટિકરક પરીક્ષણ હકારાત્મક હશે તો અમે તારણ કાઢીશું કે તમે HIVના સંપર્કમાં છો. જો કે તમે ફક્ત સ્ક્રીનીંગ અને કન્ફર્મેટીવ ટેસ્ટ બંનેમાં હકારાત્મક આવ્યા છો, તે લક્ષ્યમાં લીધા વગર તમારા બાળકનું કોર્ડ બ્લડ SCITPL ખાતે સ્ટોર કરી શકાશે નહીં.
HIV માટે હકારાત્મક પરીક્ષણનો અર્થ એ નથી કે તમને AIDS છે. જો તમારું પરીક્ષણ હકારાત્મક છે તો તમારે તમારા સ્વાસ્થ્ય સંભાળકર્તા પાસેથી સલાહ લેવી જોઈએ. તે ઉપરાંત તમે સ્થાનિક AIDS સંગઠનાઈઓગ્રન્થાની સલાહ લઈ શકો છો.
હું નીચે સહી કરનાર, મેં મારા લોહીના નમૂના (SCITPLની આવશ્યકતા મુજબ)લેવાના અને ચોક્કસ રોગોના પરીક્ષણ માટેના સંભવિત જોખમોની ઉપર્યુક્ત સંબંધિત માહિતીની મારી શ્રેષ્ઠ જાણીની ભાષામાં સમજ્યને સમીક્ષા કરી છે. હું SCITPL દ્વારા પૂરી પાડવામાં આવતી સેવામાં ભાગ લેવા માંગુ છું અને આથી નીચેની પ્રક્રિયાઓ માટે સંમતિ આપુ છું.
-
હું મારા ડોકટરને મારા બાળકના જન્મ સમયે તેનું કોર્ડ બ્લડ એકત્રિત કરવા અને મારા બાળકના જન્મના 7 દિવસની અંદર મારા લોહીનો નમૂનો લેવા મંજૂરી આપવા સંમત થાઉ છું.
-
હું કોર્ડ બ્લડની યોગ્યતાનું મૂલ્યાંકન કરવા માટે આ ગર્ભવસ્થાના મારા અને મારા બાળકના આરોગ્યલેખાના તબીબી ચાર્ટની સમીક્ષા કરવા માટે રજાકુન મંજૂરી આપવા સંમત થાઉ છું. આમાં મારા પ્રારંભિક પરીક્ષણો અને HIV I & II (AIDS કારક વાયરસ), HCV, HBV, CMV, HTLV I & II, Syphilis, Malaria, સહિતના પરીક્ષણો ધરાવતા તબીબી ઇતિહાસને તપાસવાની પરવાનગી સામેલ છે.
-
SCITPL ખાતે મારા, મારા બાળકના અને મારા બાળકના કોર્ડ બ્લડ યુનિટ વચ્ચેની કડી જાળવવામાં આવશે કે જે SCITPLને કોઈપણ પરિણામના હકારાત્મક પરિણામ અને તે કેવી રીતે મારા તથા મારા બાળકના સ્વાસ્થ્યને અસર કરી શકે છે તેની જાણ કરવાની તથા ભવિષ્યમાં સીધા સંપર્ક કરવાની મંજૂરી આપુ છું.
-
હું સંબંધિત પ્રોગ્રામ કર્મચારીઓને ભવિષ્યમાં મારા બાળકના સ્વાસ્થ્યની બાબતમાં મારો સંપર્ક કરવાની મંજૂરી આપવા સંમત છું. કારણકે વારસાગત પરિસ્થિતીઓના કેટલાક ચિન્હો અને લક્ષણો જન્મબાદના ચોક્કસ સમયગાળા સુધી દેખાતા નથી, અથવા શોધી શકાતા નથી, તેથી SCITPL મારા બાળકના જન્મ પછીના 6 થી 12 મહીનામાં વાર્સાગત રોગો અને પરિસ્થિતીઓના સંબંધિત પ્રશ્નો સહિતના અનુસરણ માટે મારો ફોન દ્વારા સંપર્ક સાધી શકે છે. જો જરૂર હોય તો તેના પછી પણ ફોન કે મેઈલ દ્વારા મારો સંપર્ક કરી શકાશે.
-
હું સંમત છું કે કોર્ડ બ્લડ યુનિટનો ઉપયોગ ફક્ત મારા નજીકના પરિવારના સભ્યો માટે જ કરી શકાશે.
-
જો કોઈપણ કારણસર, કરારની કોઈપણ શરત મારા દ્વારા અનુસરણ નહીં તો હું SCITPLને મારા કોર્ડ બ્લડ યુનિટનો ઉપયોગ જરૂરીયાતમંદ દર્દી, દિલનીકુ ટ્રાયલ માટે કરવા તથા કોર્ડ બ્લડના યુનિટના પુન:પ્રાપ્તિ વિશે મને જાણ કરવા માટેની મંજૂરી આપવા સંમત થાઉ છું.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 21
મારું કોર્ડ બ્લડ સંગ્રહ માટે યોગ્ય છે કે નહીં તે નિર્ધારીત કરવા, મારા લોહીના નમૂનામાંથી ચોક્કસ ચેપી રોગોના પરીક્ષણની વ્યવસ્થા કરવા માટે SCITPL સાથે સંમત છું.
-
વિશિષ્ટ પરીક્ષણો આ મુજબ છે- HIV (AIDS કારક virus), Hepatitis B અને Hepatitis C, Syphilis, Malaria, Human-T-Lymphotropic Virus (HTLV 1 & 2), Cytomegalovirus (CMV) અને અન્ય આવશ્યક પરીક્ષણો.
-
હું સંગ્રહ અને/અથવા પ્રત્યારોપણ માટેના કોર્ડ બ્લડની ઓળખ અને તેની યોગ્યતાનું મૂલ્યાંકન કરવા માટે મારા બાળકના કોર્ડ બ્લડના Red Blood Cell type (ABO Rh), Cell Viability, Total Nucleated Cells, Sterility(શુદ્ધ જીવવિજ્ઞાનસ પરીક્ષણ) અને બીજા નિર્ધારિત કરેલા પરીક્ષણો કરવાની વ્યવસ્થા કરવા SCITPL સાથે સંમત છું.
-
મને ખ્યાલ છે કે કેટલાક પરીક્ષણો પ્રત્યારોપણ સમયે કરવામાં આવે છે.
-
હું મારા બાળકના કોર્ડ બ્લડની પ્રક્રિયાઓ અને સંગ્રહ કરવા માટેની SCITPLની સેવા મેળવવા સંમત છું.
કૃપા કરીને SCITPLની ઓફિસનો સંપર્ક કરવા નિશ્ચિત રહો. જો તમારે કોઈ પ્રશ્ન હોય તો અમારી પાસે તમારા બધા પ્રશ્નોના જવાબ આપવા માટે તથા તમારી ચિંતાઓની ચર્ચા કરવા માટે તાલીમધ્ધક કર્મચારીઓ છે.
હું સમજુ છું કે કોર્ડ બ્લડ અને મારા રકત ઉપર કરવામાં આવેલા તમામ પરીક્ષણોના પરિણામો ગોપનીય છે, અને ફક્ત મારા દ્વારા અધિકૃત કરણ તો અથવા કાયદાની જરૂરીયાત મુજબ અથવા માન્ય સંસ્થાઓની જરૂરીયાત મુજબ જાહેર કરી શકાશે. હું એ પણ સમજુ છું કે SCITPL HIV 1 & 2 માટેના કોઈપણ પરીક્ષણના હકારાત્મક પરિણામ વિશે સ્થાનિક સંચાલક સંચાઓને જાણ કરવા બંધાયેલ છે.
હું એ પણ સમજુ છું કે મારા પ્રસૂતિવિજ્ઞાની કે સ્ત્રીરોગ નિષ્ણાંત તે પણ તેના વિશે સૂચિત કરવામાં આવશે.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 22
The Client understands and has agreed that SCITPL is not responsible for, and assumes no liability for direct, indirect, punitive, incidental, special, consequential damages or any damages whatsoever arising or resulting from the action of others, including obstetrician(s), collection nurse or the hospital staff, the laboratory staff, and the courier who transports the Child's cord blood for any claims, damages, liabilities, costs or expenses arising or resulting, directly or indirectly and in no event shall SCITPL have any obligation to indemnify the Client of any claims, damages, liabilities, costs or expenses arising or resulting, directly or indirectly, out of childbirth or the Service. SCITPL assumes no responsibility for assessing the qualifications of hospital(s), obstetrician(s) or hospital nurse.
In consideration of the opportunity to use this Service, Client hereby release and forever discharge SCITPL and their affiliates, successors, assigns, officers, directors, employees, agents, independent contractor and sub-contractors collectively, (the "Related Parties") from any and all liability for any and all loss, harm, damages or claim of any kind arising from or relating to actions, causes of action and any other claims and demands of any kind whatsoever, that may arise in connection with any services provided pursuant to this Agreement, except if such claims or demand arise out of said parties' gross negligence or willful misconduct. However, the amount of damages that the Client may recover shall be limited to the amount of money paid under this Agreement.
The client understands that though all precautions are taken to minimize the microbial presence during the collection of Umbilical Cord Blood, due to the inherent nature of the birthing process itself, such risks cannot be eliminated entirely. Based on international clinical and transplant reports, microbial positive Stem Cell samples are not ruled out for transplant applications, however, the final decision rests with the transplant physician. The amount of Cord Blood may vary on various factors but not limited to size and weight of the Baby, nature of delivery and other factors.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 23
- Total Nucleated Cell Count (TNC)
- Total Mononuclear Cell Count (MNC)
- Progenitor Cell (CD34+) Count
- Progenitor Cell (CD34+) Viability
- Cellular Viability
- ABO Group and Rh Type
- Sterility Test as regards Bacterial (Aerobic/Anaerobic) and Fungal
- Human immunodeficiency virus (HIV I and II)
- Hepatitis B virus
- Hepatitis C virus
- Human T-lymphotropic virus (HTLV I & II)
- Cytomegalovirus (CMV) IgG and IgM
- Syphilis
- Malaria
- Nucleic Acid Testing (NAT)-HIV/HBV/HCV
- Total Nucleated Cell Count (TNC)
- Total Mononuclear Cell Count (MNC)
- Progenitor Cell (CD34+) Count
- Progenitor Cell (CD34+) Viability
- Cellular Viability
- Sterility Test as regards Bacterial (Aerobic/Anaerobic) and Fungal
- Hemoglobinopathy
- HLA Testing (Unit)
- HLA Testing (Recipient)
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 24
SCITPL with its global expertise of facilitating more than 2300 transplants understands the clients' needs and offers a 360 Degree protection for the Client's family through the "StemCyte Salient Features".
The below benefits are offered to the client for 21 (twenty-one) years from the date of birth of the child under the StemCyte Pro plan and shall be applicable for Child, Child's Siblings and Child's Parents.
If the Child's stored Cord Blood Unit or Additional Unit is to be used in an approved transplant, under the Safeguard Program SCITPL assures monetary benefit up to ₹20,00,000/- (Rupees Twenty Lakhs only).
Note: Will Transportation be FOC for additional unit, how many additional units will be provided ?
In any event a Cord Blood Unit apart from the Child's Stored Cord Blood is required for use in an approved transplant or approved clinical trial either collectively or independently then SCITPL shall arrange a Highest HLA Matching Cord Blood Unit from its Public Bank Inventory at no extra cost to the client. The Additional Unit shall also be provided in an event the child's own stored cord blood unit is utilized and no longer available.
If child's Cord Blood stem cells are used in an approved transplantation and fails to engraft (as per the guidelines benchmarked against international best practices), SCITPL will provide a highest HLA matched unit from StemCyte Public Bank inventory. If SCITPL cannot find one Unit from StemCyte Public Bank inventory, then SCITPL agrees to pay up to ₹20,00,000/- (Rupees Twenty Lakhs) to find and purchase a suitably matched Unit through worldwide registries.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 25
The unit shall be stored for 75 (seventy-five) years and the below benefits are offered to the client for 21 (twenty-one) years from the date of birth of the child under the StemCyte Prime plan and shall be applicable for Child, Child's Siblings, Child's Parents and Child's Grandparents (Maternal and Paternal).
If the Child's stored Cord Blood Unit or Additional Unit is to be used in an approved transplant, under the Safeguard Program SCITPL assures monetary benefit up to ₹20,00,000/- (Rupees Twenty Lakhs only).
Note: Is transportation and testing for additional unit covered in the plan ?
In any event a Cord Blood Unit apart from the Child's Stored Cord Blood is required for use in an approved transplant or approved clinical trial either collectively or independently then SCITPL shall arrange a Highest HLA Matching Cord Blood Unit from its Public Bank Inventory at no extra cost to the client. The Additional Unit shall also be provided in an event the child's own stored cord blood unit is utilized and no longer available.
The client is entitled to get multiple additional units under this plan.
If child's Cord Blood stem cells are used in an approved transplantation and fails to engraft (as per the guidelines benchmarked against international best practices), SCITPL will provide a highest HLA matched unit from StemCyte Public Bank inventory. If SCITPL cannot find one Unit from StemCyte Public Bank inventory, then SCITPL agrees to pay up to ₹20,00,000/- (Rupees Twenty Lakhs only) to find and purchase a suitably matched Unit through worldwide registries.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 26
The unit shall be stored for 75 (seventy-five) years and the below benefits are offered to the client for 30 (Thirty) years from the date of birth of the child under the StemCyte Elite plan and shall be applicable for Child, Child's Siblings, Child's Parents and Child's Grandparents (Maternal and Paternal).
If the Child's stored Cord Blood Unit or Additional Unit is to be used in an approved transplant, under the Safeguard Program SCITPL assures monetary benefit up to ₹60,00,000/- (Rupees Sixty Lakhs only).
In any event a Cord Blood Unit apart from the Child's Stored Cord Blood is required for use in an approved transplant or approved clinical trial either collectively or independently then SCITPL shall arrange a Highest HLA Matching Cord Blood Unit from its Public Bank Inventory at no extra cost to the client. The Additional Unit shall also be provided in an event the child's own stored cord blood unit is utilized and no longer available.
The client is entitled to get multiple additional units under this plan.
If child's Cord Blood stem cells are used in an approved transplantation and fails to engraft (as per the guidelines benchmarked against international best practices), SCITPL will provide a highest HLA matched unit from StemCyte Public Bank inventory. If SCITPL cannot find one Unit from StemCyte Public Bank inventory, then SCITPL agrees to pay up to ₹20,00,000/- (Rupees Twenty Lakhs only) to find and purchase a suitably matched Unit through worldwide registries.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 27
These are part of Service Agreement and shall be binding on both the parties.
Note: Clarify this, is this 20 Lakh per transplant even for StemCyte Elite package
a. The unit is used in an approved transplant.
b. The monetary benefit shall not exceed ₹ 20,00,000/- (Rupees Twenty Lakhs only) per transplant.
c. The disease has to be diagnosed after the cord blood unit is stored at SCITPL. Also, a written and signed prescription from the transplant physician is required.
d. Any monetary payments by SCITPL will require a time period of 30 (thirty) business days and shall be paid directly to the transplant center post verification.
e. Pre-existing diseases (in family) need to be clearly mentioned in the health history.
Additional unit can be released for below listed possibilities from StemCyte Public Bank inventory.
a. Basis on the dosage criteria.
b. HLA does not match with the child's stored Cord Blood Unit.
c. Due to unsuitability because of genetic disorders.
d. If the child's stored Cord Blood Unit does not meet the quality parameters (based on viability criteria) benchmarked against international best practices.
In case of the need for Additional Unit / Replacement Unit from StemCyte Public Bank Inventory, up on performing all the required quality tests on the Unit, it will be ready for shipment in maximum 21 (twenty-one) days from receipt of the request.
a. Time to assessment of engraftment using the usual definition of engraftment must be at least 4 (four) weeks. Valid medical records documenting proof of non-engraftment will be required. Cells must not have been subjected to positive or negative cell selection, expansion, gene therapy, or have been combined with peripheral blood, bone marrow, or a second cord blood unit. The LifeSaver Guarantee does not apply to experimental procedures.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 28
It applies for any approved hematopoietic indications/diseases as per Indian Regulatory Authorities / National Guidelines for Stem Cell Research by ICMR and DBT; diagnosed after the Unit has been stored.
Note: Critical, to be discussed
b. SCITPL does not guarantee a favorable outcome or lack of adverse events for any Stem Cell transplantation with its Units. Furthermore, SCITPL does not guarantee that an unrelated Cord Blood product that is identified for your family will be deemed acceptable to the transplant physician or transplant center, since each transplant is a complex decision.
c. This guarantee does not cover damage caused by natural disasters or Acts of God.
d. Any monetary payments by SCITPL will require a time period of 30 (thirty) business days and shall be paid directly to the respective public bank post verification.
As per the ICMR (Indian Council of Medical Research) National Guidelines for Stem Cell Research 2017; at present there is no scientific evidence to substantiate clinical benefits with the use of stem cells derived from sources other than Umbilical Cord Blood, hence commercial banking of all biological materials other than Umbilical Cord Blood is not permitted.
Respecting and obeying law of land and being an ethical company; StemCyte India Therapeutics Private Limited is not involved in preservation of Cord Tissue as an obligation towards ICMR National Guidelines for Stem Cell Research, 2017. However, StemCyte India understands the future possible regenerative therapeutics advancements that may happen with MSCs and hence gives assurance to provide MSCs (derived from donated Human Umbilical Cord Tissue) to its clients in future subject to regulatory authority approval.
SCITPL shall provide free of cost up to 500 Million MSCs derived from donated Human Umbilical Cord Tissue to the client for any approved Stem Cell transplantation by MSCs (subject to regulatory authority approval) within 90 (ninety) days from the date of request. The concerned transplant physician should give in writing with reasons for the requirement of MSCs with dosage to StemCyte India. This shall be applicable to all the clients enrolling with SCITPL for their child's cord blood preservation and shall be applicable for 21 (twenty-one) years from the date of birth of the child. The benefit of MSCs assurance shall cover the family members as per the plan chosen by the client for Cord Blood Preservation with SCITPL.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 29
Name : ________________________________________________________________________
Date of Birth : __________________________ Email ID : __________________________________________
Mobile : ________________________________ Expected Date of Delivery : ____________________________
Occupation : _________________________________________________________________________
Company Name : ____________________________________________________________________
Designation : _____________________________________________________________________
Name : ________________________________________________________________________
Date of Birth : __________________________ Email ID : __________________________________________
Mobile : ________________________________ Occupation : _______________________________________
Company Name : ____________________________________________________________________
Designation : _____________________________________________________________________
Address : _______________________________________________________________________
City : ____________________________ State : ___________________________ Pincode : ______________________
Doctor's Name : ________________________________________________________________________
Hospital Name : ________________________________________________________________________
Address : __________________________________________________________________________
State : ______________________________________ City : _______________________________________
Pincode : ________________________________ Mobile/Phone : _____________________________________
(Please inform StemCyte India in case of changes, prior to delivery)
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 30
This section contains Cord Blood - Maternal risk questionnaire (question 1 to 14 which has to be filled by child's mother) and family medical history of your first degree relative.
These questions are used in the Cord Blood Bank's evaluation of the collected Cord Blood Unit to minimize risk at the time of transplant and is important that you (child's mother) carefully read and complete the following questions to the best of your knowledge.
| YES | NO | |
|---|---|---|
| 1. Did you use a donor egg or sperm or surrogate for this pregnancy? | ☐ | ☐ |
| 2. Are you currently taking an antibiotic or any other medication for infection? | ☐ | ☐ |
| 3. Are you now taking or have you ever taken any of following medications? | ||
| a. Human Pituitary Growth Hormone or Bovine insulin | ☐ | ☐ |
| b. Hepatitis B Immune Globulin or Unlicensed vaccine | ☐ | ☐ |
| 4. In the past 8 weeks have you had any live vaccines/ shots (measles, mumps)? | ☐ | ☐ |
| 5. In the past 12 weeks have you had a smallpox vaccination or had contact with someone who had a smallpox vaccination? | ☐ | ☐ |
| 6. In the past 12 months have you | ||
| a. Been told by a healthcare professional that you have West Nile Virus (WNV) or any positive test for same? | ☐ | ☐ |
| b. Had a blood transfusion? | ☐ | ☐ |
| c. Had and accidental needle-stick or came into contact with someone else's blood? | ☐ | ☐ |
| d. Had a tattoo or ear or body piercing? | ☐ | ☐ |
| e. Had a transplant or graft from someone other such as organ, bone marrow, stem cell, cornea, sclera, bone, and skin or other tissue? | ☐ | ☐ |
| f. Had lived or had sexual contact with a person who has hepatitis? | ☐ | ☐ |
| g. Had a sexual contact with someone who has HIV / AIDS or has had a positive test for the HIV / AIDS virus? | ☐ | ☐ |
| h. Had sexual contact with anyone who has ever used needles to take drugs or steroids or anything not prescribed by their doctor? | ☐ | ☐ |
| i. Had sexual contact with a male who has ever had sexual contact with another male? | ☐ | ☐ |
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 31
| YES | NO | |
|---|---|---|
| j. Had sexual contact with a prostitute or anyone else who takes money or drugs or other payment for sex? | ☐ | ☐ |
| k. Had or been treated for syphilis or other sexually transmitted infections? | ☐ | ☐ |
| l. Been in juvenile detention, lockup, jail or prison for more than 72 hours? | ☐ | ☐ |
| 7. Have you ever had | ||
| a. Any positive test for HIV / AIDS virus? | ☐ | ☐ |
| b. Hepatitis? | ☐ | ☐ |
| c. Malaria? | ☐ | ☐ |
| d. Chagas Disease? | ☐ | ☐ |
| e. Any positive test for T. cruzi? | ☐ | ☐ |
| f. Bebesiosis? | ☐ | ☐ |
| g. Received a dura mater (or brain covering) graft? | ☐ | ☐ |
| h. Been in Africa or had sexual contact with anyone who was born in or lived in Africa? (Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, Nigeria, Senegal, Togo, Zambia, Benin, Kenya) | ☐ | ☐ |
| i. Had (including your sexual partner or a member of your household) a transplant or other medical procedure that involved being exposed to live cells, tissues, or organs from an animal? | ☐ | ☐ |
| j. Tested positive for HTLV, had adult T-cell leukemia, or had unexplained paraparesis (partial paralysis affecting the lower limbs)? | ☐ | ☐ |
| 8. Have any of your relatives, the Child's Father or any of the Child's other relatives had Creutzfeldt-Jakob disease? | ☐ | ☐ |
| 9. Medical diagnosis of Zika Virus (ZIKV) infection at any point during pregnancy? | ☐ | ☐ |
| 10. Residence in or travel to an area with active ZIKV transmission at any point during pregnancy? | ☐ | ☐ |
| 11. Sex at any point during pregnancy with a male who had active ZIKV transmission in past six months? | ☐ | ☐ |
| 12. From 1980 through 1996, did you spent time that adds up to three (3) months or more in the United Kingdom (UK) (England, North Ireland, Scotland, Wales, Isle of Man, Channel Island, Gibraltar, Falkland Island) | ☐ | ☐ |
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 32
| YES | NO | |
|---|---|---|
| 13. From 1980 to the present, | ||
| a. Have you spent five (5) years or more in Europe? | ☐ | ☐ |
| b. Received a blood transfusion or blood components in the United Kingdom (UK)? | ☐ | ☐ |
| 14. In the past 5 years have you | ||
| a. Received money, drugs or other payment for sex? | ☐ | ☐ |
| b. Used needles to take drugs, steroids or anything not prescribed by your doctor? | ☐ | ☐ |
| Question No. | Explanation |
|---|---|
| Ex. 7 C | Had malaria in 2012. |
☐ I (Child's Mother) have answered all the questions to the best of my knowledge after reading and understanding all the information presented to me regarding cord blood collection, processing and preservation.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 33
For the under mentioned questions please use following codes to describe the relation between the child and the family member with the said disease :
CM - Child's Mother, CF - Child's Father, CGP - Child's Grand Parents (Maternal & Paternal), CS - Child's Siblings
| YES | NO | |
|---|---|---|
| 15. Are you preserving your Child's Cord Blood for a designated patient? | ☐ | ☐ |
if yes, please provide below details :
| WHO | REASON |
|---|---|
| Ex. Child's Sibling (CS) | Ex. Treatment of Thalassaemia |
| 16. Any blood relatives with cancer / leukemia before 20 years of age? | ☐ | ☐ |
if yes, please provide below details :
| WHO | WHICH DISEASE |
|---|---|
| Ex. Child's Grand Parent (CGP) | Ex. Leukemia |
| 17. Any red cell, white cell, platelet related disease or any metabolic/storage disease or any disease of immune deficiency / genetic disease / neurological disorders / inherited disorders / genetic abnormalities ? | ☐ | ☐ |
if yes, please provide below details :
| WHO | WHICH DISEASE/ABNORMALITY |
|---|---|
| Ex. Child's Father (CF) | Ex. Thalassemia Carrier |
I (child's mother) hereby acknowledge that I have read, understand, and agreed to the terms and conditions of this agreement. Also, the information and answers given by me are true to the best of my knowledge and I take full responsibility for the same. SCITPL holds the right to evaluate any answer(s) tick marked "Yes" as per its Standard Operating Procedure (SOP).
| Authenticated By Parent | Reviewed By Laboratory, SCITPL | Chief Operating Officer, SCITPL |
|---|---|---|
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 34
The following pages are for StemCyte India office use only.
Area / Region : __________________________________________ Date : ______________________________
Name of Executive : ______________________________ Name of Manager : ____________________________
Name of Mother : ______________________________________ UID (Barcode) : ___________________________
| PLAN | PLAN OPTED | LIST PRICE* | FINAL PRICE (₹) | FINAL PRICE INCLUDING GST (₹) |
|---|---|---|---|---|
| StemCyte Pro | ☐ | ₹ 55,000 /- | ||
| StemCyte Prime | ☐ | ₹ 70,000 /- | ||
| StemCyte Elite | ☐ | ₹ 80,000 /- |
* 18% GST extra is applicable on above List Price
☐ PAN Card ☐ Aadhaar Card ☐ Passport ☐ Election Card ☐ Driving Licence
| PLAN | LIST PRICE* | ENROLMENT FEES | | PROCESSING & STORAGE FEES |
| REGISTRATION FEES | KIT & LOGISTICS | |||
|---|---|---|---|---|
| StemCyte Pro | ₹ 55,000 /- | ₹ 10,000 /- | ₹ 7,000 /- | ₹ 38,000 /- |
| StemCyte Prime | ₹ 70,000 /- | ₹ 10,000 /- | ₹ 7,000 /- | ₹ 53,000 /- |
| StemCyte Elite | ₹ 80,000 /- | ₹ 10,000 /- | ₹ 7,000 /- | ₹ 63,000 /- |
* 18% GST extra is applicable on above List Price
Notes :
- Cord Blood Unit Collection Charges shall be extra as applicable.
- All Cheques to be collected at the time of Enrollment.
- Cheques only of scheduled banks will be accepted.
- In the event of dishonour of cheque, ₹ 500 will be charged extra in each case.
- Any taxes/other charges if applicable shall be collected / recovered from the client as per Government regulations with retrospective effect.
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001 Email : [email protected] | Call : +91 99099 29988 | Website : www.stemcyteindia.com
PAGE - 35
STEMCYTE USA
STEMCYTE INDIA
STEMCYTE TAIWAN
Accreditations: Fact NetCord, AABB, DCGI, NMDP, CPC, JAS-ANZ, FDA Registered, iSBT 128, Cord Blood Association
StemCyte India Therapeutics Pvt. Ltd.
Apollo Hospital Campus, Plot No. 1A, Bhat GIDC Estate, Dist. Gandhinagar - 382 428, Gujarat, India. Phone : 079 - 61701001, Email : [email protected] Call : +91 99099 29988, Website : www.stemcyteindia.com
Let's Get Social!
[Facebook] [LinkedIn] [Instagram] [YouTube] [Twitter] [Threads]
DRAFT COPY