Enrollment Form & Client Agreement
Name: .......................................................................... CRM No.: ..................................................................... APP. No.: ...................................................................... Country :.......................................................................
APP. NO.............................................
CRM NO.
EXHIBIT - 1: ENROLLMENT FORM - EXPECTANT PARENTS’ DETAILS To be filled in BLOCK LETTERS only using black ink ball-point pen
PERSONAL DETAILS Mother’s Name Husband's Name Mother’s Date of Birth Communication Address
Landmark City
State
Country
Pin Code
Telephone (Home) Telephone Number
STD Code
Mobile 1
Mobile 2 Mobile Number
Mobile Number
E-mail ID If Permanent Address is same as Communication Address (Tick) Permanent Address (If different from above)
Landmark State
City
Pin Code
Country Identity Proof
Husband
Client
Identification provided
PAN
Passport
Driving Licence
Voter ID
Other
If ‘Other’, please specify ID Proof No. If you are an existing LifeCell Client, provide 12 digit CRM No.
HOSPITAL & BIRTHING DETAILS Expected Date of Delivery Type of Pregnancy (Tick)
Single Birth
Twins
Triplets
Quads
Consulting Gynecologist Name Consulting Hospital Name Consulting Hospital Address
Landmark City
State
Country
Pin Code
Telephone STD Code
President, LifeCell International
Telephone Number
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 1 of 24
APP. NO.............................................
CRM NO.
Delivering Hospital Details (if different from consulting Gynaecologist)
Gynaecologist Name Hospital Name Hospital Address
Landmark City
State
Country
Pin Code
Telephone Country Code
Telephone Number
Mobile Number
SHIPMENT DETAILS Send Collection kit to (Tick) Shipping Address (if different from above)
Communication Address
Permanent Address
Landmark City
State
Country
Pin Code
Telephone Country Code
Telephone Number
DETAILS OF REFERENCE If referred by an existing Client, please provide details as below: Referring Client’s Name Referring Client’s CRM
Mobile / Phone
TICK AS APPLICABLE FOR LIFECELL SUPPORT SERVICE: Requesting LifeCell to arrange for pick up of Maternal sample and Specimen Requesting LifeCell to organise for Phlebotomist
I confirm that the information provided above is correct to the best of my knowledge and I also agree to keep LifeCell informed incase of change of above details for future communication.
Signature of Client Name:
Signature of Birth Mother if not Client
Signature of Husband Name:
Name:
Date:
For LifeCell use only Name of LifeCell Executive LifeCell Authorised Signature Name of Signatory:
President, LifeCell International
Employee Code
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 2 of 24
APP. NO. ........................................... CRM NO.
EXHIBIT -2: FEE SCHEDULE Plan Name & Description
Amount in ` Protect Baby Protect Mom
BabyCord
BabyCord Duo
5,000 29,000 2,000
5,000 39,500 2,500
5,000 63,000 4,000
36,000
47,000
72,000
2,000
2,500
4,000
59,900
74,900
1,19,900
A) ANNUAL STORAGE PLAN
Enrollment Fee Processing Fee First year storage fee Total Initial Payment Annual Storage Fee(20 years) B) 21 YEAR STORAGE PLAN Enrollment, processing and storage fee for 21 years (No annual storage plan)
21 YEAR STORAGE - EMI PLANS C) 24 EMI* Enrollment, processing and storage fee for 21 years (No annual storage plan)
2 ,600
3,250
5,000
5,000
6,250
10,000
10,000
12,500
20,000
D) 12 EMI* Enrollment, processing and storage fee for 21 years (No annual storage plan)
E) 6 EMI* Enrollment, processing and storage fee for 21 years (No annual storage plan)
*First two EMI’s should be paid in advance
Value added service
Optional service which can be combined with any of the above services
10,000
Dual Storage-21 Year Storage
Description of Service BabyCord BabyCord Duo Protect Baby, Protect Mom
PY O C LL E C LIFE
Testing, processing and storage of minimally manipulated cord blood stem cells obtained from Child.
Testing, processing and storage of minimally manipulated umbilical cord blood & cord tissue stem cells and not less than 1 Million umbilical cord tissue derived mesenchymal stem cells. Testing, processing and storage of minimally manipulated umbilical cord blood & cord tissue stem cells and not less than 1 Million umbilical cord tissue derived mesenchymal stem cells obtained from Child. Testing, processing and storage of minimally manipulated and minimally expanded menstrual blood stem cells obtained from Client.
I wish to enrol for (Tick)
BABYCORD
Payment Plan
21 year Storage
Value Added Service
BABYCORD DUO
PROTECT BABY, PROTECT MOM
12 EMI
6 EMI
24 EMI
Dual Storage - 21 year Storage
PAYMENT BY CREDIT CARD Credit Card mandate (to be filled-in by the Credit Card member) Please charge my credit card as per below details Credit Card No.: Amount to be charged
Debit Cards are not accepted Card Expiry Date: Type of card:
Declaration of Card member: I hereby declare that the credit card particulars given above are correct and complete. If the transaction is delayed or not effected at all for reasons of incomplete or incorrect information, I would not hold LifeCell responsible. Name of Credit Card Member Note: Cash payment will not be accepted
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 3 of 24
AGE P S I TH
BLA T F E LY L L A N TIO N E T IS IN
NK
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 4 of 24
APP. NO. ........................................... CRM NO.
EXHIBIT -2: FEE SCHEDULE Plan Name & Description
Amount in ` Protect Baby Protect Mom
BabyCord
BabyCord Duo
5,000 29,000 2,000
5,000 39,500 2,500
5,000 63,000 4,000
36,000
47,000
72,000
2,000
2,500
4,000
59,900
74,900
1,19,900
A) ANNUAL STORAGE PLAN
Enrollment Fee Processing Fee First year storage fee Total Initial Payment Annual Storage Fee(20 years) B) 21 YEAR STORAGE PLAN Enrollment, processing and storage fee for 21 years (No annual storage plan)
21 YEAR STORAGE - EMI PLANS C) 24 EMI* Enrollment, processing and storage fee for 21 years (No annual storage plan)
2 ,600
3,250
5,000
5,000
6,250
10,000
10,000
12,500
20,000
D) 12 EMI* Enrollment, processing and storage fee for 21 years (No annual storage plan)
E) 6 EMI* Enrollment, processing and storage fee for 21 years (No annual storage plan)
*First two EMI’s should be paid in advance
Value added service
Optional service which can be combined with any of the above services
10,000
Dual Storage-21 Year Storage
Description of Service BabyCord
CLIE
PY O C NT
Testing, processing and storage of minimally manipulated cord blood stem cells obtained from Child.
BabyCord Duo
Testing, processing and storage of minimally manipulated umbilical cord blood & cord tissue stem cells and not less than 1 Million umbilical cord tissue derived mesenchymal stem cells.
Protect Baby, Protect Mom
Testing, processing and storage of minimally manipulated umbilical cord blood & cord tissue stem cells and not less than 1 Million umbilical cord tissue derived mesenchymal stem cells obtained from Child. Testing, processing and storage of minimally manipulated and minimally expanded menstrual blood stem cells obtained from Client.
I wish to enrol for (Tick)
BABYCORD
Payment Plan
21 year Storage
Value Added Service
BABYCORD DUO
PROTECT BABY, PROTECT MOM
12 EMI
6 EMI
24 EMI
Dual Storage - 21 year Storage
PAYMENT BY CREDIT CARD Credit Card mandate (to be filled-in by the Credit Card member) Please charge my credit card as per below details Credit Card No.: Amount to be charged
Debit Cards are not accepted Card Expiry Date: Type of card:
Declaration of Card member: I hereby declare that the credit card particulars given above are correct and complete. If the transaction is delayed or not effected at all for reasons of incomplete or incorrect information, I would not hold LifeCell responsible. Name of Credit Card Member Note: Cash payment will not be accepted
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 5 of 24
AGE P S I TH
BLA T F E LY L L A N TIO N E T IS IN
NK
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 6 of 24
UMBILICAL CORD STEM CELL TESTING, PROCESSING, STORAGE AND INFORMED CONSENT AGREEMENT I/We, the undersigned (the ‘Client’), on behalf of myself/ourselves and my/our unborn Child (the ‘Child’), engage LifeCell International Private Limited, a company incorporated under the Companies Act, 1956, and having its registered office at 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai 600127, India (‘LifeCell’), this day of ........................, 201… (the ‘Enrollment Date’), to process, test, and store stem cells obtained from the umbilical cord blood and/or stem cells from umbilical cord tissue collected at birth of the Child (‘Services’) on the following terms (this ‘Agreement’). 1.
DEFINITIONS
3.2.
Client is responsible for providing the Collection Kit to the Caregiver and arranging for collection, preparation and labeling of the Maternal Blood and Specimen for delivery to LifeCell along with the duly f illed up forms included in the Collection Kit, unless the same has been assigned to LifeCell.
3.3.
Client must promptly notify LifeCell in writing of any change in Client's name or current mailing address or in the legal guardianship of the Child.
4.
DUAL STORAGE
4.1.
For disaster management, back-up and added retention security, LifeCell at the request of the Client and payment of additional fees will store the Specimen simultaneously in both of its licensed facilities situated at #26, Vandalur Kelambakkam Main Road, Keelakottaiyur, Chennai 600127, Tamil Nadu, and Plot #26, Sector 4, IMT Manesar, Gurgaon 122001, Haryana.
In this Agreement, (including the recitals above), unless the context otherwise requires, the following expressions shall have the following meanings: 1.1.
‘Child’ means the Client’s baby from whom the Specimen will be collected following his/her birth.
1.2.
‘Client’ means the parent or legal guardian of the Child.
1.3.
‘Caregiver’ means the Obstetrician Gynecologist or qualif ied medical professional/midwife who will be assisting in delivering the Child.
1.4.
‘Maternal Blood’ means peripheral blood from Birth Mother of the Child, that has been drawn by observing standard phlebotomy procedures, taken seven [7] days before or after the birth of the Child.
CE E F I L
1.5.
‘Specimen’ means and includes stem cells obtained from umbilical cord blood and/or umbilical cord tissue individually or collectively.
1.6.
‘Collection Kit’ means the kit consisting of all essential materials required for the purpose of collection and labeling of the Maternal Blood and Specimen.
2.
SERVICES: OPTION AND FEES
2.1.
LifeCell offers its umbilical cord banking services under different plans, fees and payment methods as detailed in Exhibit 2, which the Client must choose at the time of Enrollment by completing the Exhibit 2.
2.2.
Client may also choose to subscribe for additional services as listed in Exhibit 2 and pay the additional fees.
2.3.
All applicable taxes including but not limited to service tax is payable by the Client.
3.
CLIENT RESPONSIBILITIES
3.1.
Prior to the birth of the Child, the Client must complete all the applicable Exhibits [1 to 8] and make due payment of fees. If surrogate, egg donor or sperm was used, each must fill out Exhibit 3.
President, LifeCell International
PY O C LL 4.2
LifeCell has the option to relocate the Specimen and will provide notice to Client within 60 days of relocation.
5.
TERM OF AGREEMENT
5.1.
If the Client signs-up for the Annual Storage Plan, this Agreement will continue for one year from the date of birth of the Child (renewal date) and will automatically renew for successive one year period until the Child attains the age of 21 Years. This automatic renewal is subject to the Client paying the annual storage fee on or before the renewal date every year.
5.2.
If the Client signs-up for 21-Year Storage Plan, this Agreement will continue for twenty one (21) years from the date of birth of the Child.
5.3.
At least three (3) months before the expiration of the 21 year period, LifeCell shall intimate the Client (and/or Child in case the Child has come of Age) regarding the expiry of the Agreement, along with terms for continued storage. Accordingly the Client or Child can enter into a new Agreement and continue the storage.
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 7 of 24
6.
REPRESENTATIONS AND WARRANTIES OF CLIENT
8.4.
Disaster Relief: If the Client, Child, or Child’s sibling is diagnosed after the enrolment date for a hematological condition treatable by stem cell transplantation and should for any unforeseen reason that is beyond the reasonable control of LifeCell which may potentially deteriorate or cause loss of the Specimen during transit or processing or storage, LifeCell will use its best endeavors to find a unit of suitable match (as confirmed by the transplant physician) within 30 days failing which pay the Client Rs. 1,000,000 (Rupees One Million Only).
8.5.
Quality Guarantee: If the Client, Child or Child’s sibling is diagnosed after the enrolment date for a hematological condition treatable by stem cell transplantation and should for any reason the Specimen upon retrieval not meet LifeCell's then prevailing viability criteria benchmarked against existing international best practices, LifeCell will use its best endeavors to find a unit of suitable match (as confirmed by the transplant physician) within 30 days failing which pay the Client Rs. 1,000,000 (Rupees One Million Only).
8.6.
Worldwide Shipment Guarantee: There is no fee payable by the Client to LifeCell for retrieval of Specimen, including any additional testing related to release of Specimen for transplant. The Specimen will be available for delivery within 7 days or 90 days if cellular expansion is required. In the event of a transplant upon Client’s request LifeCell shall arrange and pay for X-free transport of the Specimen under cryogenic conditions to any destination worldwide.
Client represents and warrants that 6.1.
She / he is the parent or legal guardian to the Child.
6.2.
Client has had the opportunity to read, understand, review and consult with the Client's own legal counsel and medical professional, this Agreement, its Exhibits, possible risks of collection, processing, storage and possible future use of the Specimen.
6.3.
The decision to collect the Specimen and Maternal Blood, test the Maternal Blood and process and store the Specimen is a completely voluntary act of Client.
7.
RIGHTS TO SPECIMEN
7.1.
The Client shall have control over the Specimen until the Child attains majority, further to which all rights shall be automatically transferred to the Child.
7.2.
If there is a disagreement between parents the Mother’s wish shall prevail.
7.3.
The Client undertakes to inform the Child promptly of his/her right with regards to the Specimen on the Child attaining majority, including the right to renew this Agreement.
8.
LIFECELL CLIENT BENEFIT PROGRAMS
CE E F I L
LifeCell understands the Client’s need to enhance the value of their investment and also provide a comprehensive coverage for their Child. Therefore LifeCell through its Client Benefit Programs provides additional guarantees, insurances, and benefits which are detailed below: 8.1.
8.2.
8.3.
Medical Insurance: If the Client, Child or Child’s sibling is diagnosed after the enrolment date for a hematological condition treatable by stem cell transplantation the Client under the LifeCell Cares Program can avail up to Rs. 1,000,000 (Rupees One Million only) to offset transplant related expenses including but not limited to procurement of an additional unit from any public cord blood registry worldwide. Storage Insurance: In case of demise of the earning member of the family, LifeCell would continue storage of the Specimen at LifeCell’s own cost for the remaining term of the Agreement (for clients who have chosen the 21-Year Storage Plan, LifeCell would issue a pro-rated refund the storage fees). Entitlement to Full Refund: LifeCell understands that the life and health of the Mother and Child are the utmost priority. In the event the Specimen is not collected due to this priority, LifeCell shall refund all fees paid by Client to LifeCell upon sharing of relevant declaration from the attending gynecologist.
President, LifeCell International
PY O C LL 8.7.
Stem Cell Expansion Guarantee: In the event of a transplant of umbilical cord tissue stem cells LifeCell shall at its own cost expand and provide upto 500 million mesenchymal stem cells.
8.8.
Medical Concierge: For all medical and travel information relating to stem cell transplant using the stored specimen for the Baby or his/her immediate family members, LifeCell will ensure to provide, at no extra cost to the Client, the relevant information regarding leading transplant physicians, approved and credible medical transplant institutions including medical travel information relating to the Baby along with his/her immediate family members.
8.9.
General conditions for LifeCell Client Benefit Programs:
a) b) c)
The Client Agreement is valid and is in force. Payments would be made within 30 days on appropriate verification of Client’s request by LifeCell. In case of retrievals for transplant the Client has to submit duly filled up Retrieval Form (to be accompanied by Transplant Physician’s Certificate confirming end use in statutorily compliant transplant procedures).
9.
LIFECELL ASSURANCE LifeCell hereby assures that:
9.1.
LifeCell shall obtain all statutory permissions and licenses that are required for providing the services contemplated under this Agreement.
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 8 of 24
11 9.2.
LifeCell will provide the Client with the following immediately upon enrollment a Collection Kit compliant with International Air Transport Association [IATA] regulations, and a unique Client Relationship Management (CRM) number that enables the Client to quote for all communications with LifeCell.
9.3.
At the request of the Client, LifeCell would arrange and pay for qualified Phlebotomist for the collection of Maternal Blood and Specimen, and/or a certified Service Provider for X-Ray free transport of the Maternal Blood and Specimen to LifeCell’s Laboratory, provided however that the Client provides reasonable notice (not less than two hours prior to childbirth) to LifeCell for allowing the LifeCell arranged Phlebotomist to reach the venue of childbirth.
9.4.
Upon receipt of the Maternal Blood and Specimen LifeCell would determine whether it is fit or unfit for testing, processing and / or storage.
9.5.
In any event of Specimen found to be unfit, including but not limited to insufficient volume, low cell count / viability, positive screening of infectious diseases, microbial contamination of Specimen, etc., LifeCell will notify the Client immediately and seek instructions for disposal of the Specimen. If LifeCell does not receive written instructions within 30 days of such intimation then LifeCell shall continue storing the Specimen as is where is, however the benefits available under LifeCell Client Benefit Programs as per clause 8 shall not be applicable.
9.6.
In the event of Maternal Blood found to be unfit or not provided LifeCell will notify the Client immediately and seek another collection. If the Maternal Blood is not provided within 7 days of childbirth the Specimen can be used only for autologous purposes.
CE E F I L
9.7.
The Specimen would be tested, processed and stored in accordance to approved Standard Operating Procedures and in compliance with statutory regulations.
10.2.
LifeCell disclaims any responsibility to provide any other services and third party service providers like Phlebotomist, Transporter, etc shall have the respective liability for their services including loss, damage, delay in delivery, etc.
10.3.
Client agrees that LifeCell‘s liability for any loss, harm, damage or claim of any kind in connection with this agreement or the services provided by LifeCell shall be limited to the return of an amount equal to all fees paid by Client to LifeCell or benefits available under the applicable LifeCell Client Benefit Programs (whichever is higher), except for acts committed by LifeCell that are intentional and/or grossly negligent.
11.
FORCE MAJEURE Client agrees that LifeCell’s liability for causes or circumstances which are beyond LifeCell’s reasonable control shall be limited to that committed under the “Disaster Relief” program.
12.
TERMINATION OF AGREEMENT
12.1.
This Agreement may be terminated
a)
by Client at any time prior to collection of Specimen, or
b)
by Client or Child (on attaining majority) at any time prior to the retrieval of the Specimen, or
PY O C LL c)
by LifeCell if it has exercised its right to refuse Specimen processing and / or storage for any reason, including the consequential act of sample rejection as per clause 9.5, or
d)
by LifeCell if any payment due to LifeCell is not timely paid and such failure to pay is not cured within 30 days after receipt of notice from LifeCell of such failure to pay, without prejudice to LifeCell’s right to take legal steps to recover the debt. Or
e)
by mutual agreement of Client and LifeCell, or
9.8.
The Specimen would be cryopreserved at its licensed facilities throughout the term of this Agreement.
f)
by either party upon 60 days prior written notice to the other party hereto, or
9.9.
Upon successful collection, processing and storage, LifeCell will provide the Client with a Preservation Certificate confirming successful storage of the Specimen along with sample storage details and test results.
g)
in the event the Specimen is retrieved for a transplant. However, if the Client retrieves only a portion of the Specimen, the Agreement would survive along with all benefits for the term of the agreement.
9.10.
The Specimen will be marked and referred to only by the CRM number and shall not directly refer to the Client or Child. Personal Identifiable Data of the Client or Child will not be disclosed to any third party without express written permission.
h)
in the event, the Specimen is lost or destroyed for reasons beyond LifeCell’s control.
i)
in the event either law or a governmental agency or regulatory provisions or medical guidelines require us to terminate the Agreement.
12.2.
Effects of Termination:
a)
If the Agreement is terminated under Section 12.1.(a) only the Processing and Storage Fees would be refunded.
b)
If the Agreement is terminated under Section 12.1.(b) all fees paid by the Client to LifeCell are non-refundable.
10.
DISCLAIMER & LIMITATIONS:
10.1.
LifeCell does not perform any medical services, give any medical advice, or otherwise perform any service other than those expressly indicated in this Agreement. It disclaims all other representations, guarantees, warranties or assurances, express or implied.
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 9 of 24
c)
If the Agreement is terminated under Section 12.1.(c) the Storage and / or Processing Fees would be refunded as applicable.
d)
If the Agreement is terminated under Section 12.1.(d), Client relinquishes all rights in and to the Specimen and waives all claims to the Specimen and LifeCell shall have the right at its sole discretion to dispose of the Specimen. However, LifeCell shall continue storing the Specimen with no liabilities to the Client for a period of two years from the date of termination. During this period the Client shall have the option of reviving the Agreement by paying all unpaid fees and a re-enrollment fee.
e)
If the Agreement is terminated by LifeCell under Section 12.1.(f), LifeCell shall at its own cost arrange for transfer of Specimen to a comparable stem cell bank facility and pay the new stem cell bank for storing the Specimen for the remaining period of the Agreement.
f)
If the Agreement is terminated under Sections 12.1.(e) or 12.1.(g) a pro-rated refund of the prepaid storage fees will be made by LifeCell to the Client.
g)
13.
All refunds by LifeCell shall be processed within 30 days of receiving the completed documentation.
GOVERNING LAW AND JURISDICTION
MULTIPLE BIRTHS In the event of multiple births, if the Client desires to engage LifeCell to process, and store the cord blood and/or cord tissue for each Child, the Client must check the appropriate box on the Enrollment Form and pay the additional fees.
17.
ASSIGNMENT LifeCell may assign this Agreement to any individual or entity providing a similar service. If LifeCell is acquired by or merged with or into another company, LifeCell shall require that the terms of this Agreement continue in full force and effect. LifeCell shall notify the Client within 90 days in the event of any such assignment.
18.
NOTICE
18.1.
Notice to LifeCell must be in writing and delivered to LifeCell International Private Limited, #26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai – 600127.
18.2.
Notice to Client will be in writing and delivered to the address set forth in the Enrollment form or as updated by Client to LifeCell.
PY O C LL E C LIFE
This Agreement is governed by, construed and interpreted in accordance with the laws of India. Courts in Chennai shall have exclusive jurisdiction. 15.
16.
ARBITRATION All disputes arising out of or relating to this Agreement will be resolved by arbitration. The arbitration will take place In Chennai, Tamilnadu, India. The Arbitration would be governed by the Arbitration and Conciliation Act, 1996.
14.
the Child hereby agrees to the release of information to the hospital, laboratory or physician providing the services to the Client.
19.
This Agreement and the exhibits hereto constitute the entire agreement between LifeCell and Client and supersedes any prior agreements or understandings, oral and written. This Agreement may be modified only by written agreement of Client and Authorised Signatory of LifeCell.
20.
SURVIVAL All provisions which by their terms require performance after the termination of this Agreement will survive the termination of this Agreement
CONFIDENTIALITY; CONSENT TO RELEASE LifeCell acknowledges the confidential nature of the Information provided to it and agrees to use its best efforts to maintain the confidentiality of the information except as required by law or as permitted by this Agreement. All conf idential information and personal identif iable information shall be kept on secure database with adequate backup measures. Client and, if different, the Birth Mother of
ENTIRE AGREEMENT
21.
SEVERABILITY If any part of this Agreement is found to be invalid or unenforceable, such provision is deemed modified to the extent necessary to make the Agreement enforceable, and this Agreement shall otherwise remain in full force and effect.
I ACCEPT ALL TERMS AND CONDITIONS OF THIS AGREEMENT
Name and Signature of Father/Legal Guardian
Name and Signature of Mother/Legal Guardian
Name of Birth Mother if not Client Signature of Birth Mother if not Client Date:
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 10 of 24
UMBILICAL CORD STEM CELL TESTING, PROCESSING, STORAGE AND INFORMED CONSENT AGREEMENT I/We, the undersigned (the ‘Client’), on behalf of myself/ourselves and my/our unborn Child (the ‘Child’), engage LifeCell International Private Limited, a company incorporated under the Companies Act, 1956, and having its registered office at 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai 600127, India (‘LifeCell’), this day of ........................, 201… (the ‘Enrollment Date’), to process, test, and store stem cells obtained from the umbilical cord blood and/or stem cells from umbilical cord tissue collected at birth of the Child (‘Services’) on the following terms (this ‘Agreement’). 1.
DEFINITIONS
3.2.
Client is responsible for providing the Collection Kit to the Caregiver and arranging for collection, preparation and labeling of the Maternal Blood and Specimen for delivery to LifeCell along with the duly f illed up forms included in the Collection Kit, unless the same has been assigned to LifeCell.
3.3.
Client must promptly notify LifeCell in writing of any change in Client's name or current mailing address or in the legal guardianship of the Child.
4.
DUAL STORAGE
4.1.
For disaster management, back-up and added retention security, LifeCell at the request of the Client and payment of additional fees will store the Specimen simultaneously in both of its licensed facilities situated at #26, Vandalur Kelambakkam Main Road, Keelakottaiyur, Chennai 600127, Tamil Nadu, and Plot #26, Sector 4, IMT Manesar, Gurgaon 122001, Haryana.
In this Agreement, (including the recitals above), unless the context otherwise requires, the following expressions shall have the following meanings: 1.1.
‘Child’ means the Client’s baby from whom the Specimen will be collected following his/her birth.
1.2.
‘Client’ means the parent or legal guardian of the Child.
1.3.
‘Caregiver’ means the Obstetrician Gynecologist or qualif ied medical professional/midwife who will be assisting in delivering the Child.
1.4.
‘Maternal Blood’ means peripheral blood from Birth Mother of the Child, that has been drawn by observing standard phlebotomy procedures, taken seven [7] days before or after the birth of the Child.
CLIE
PY O C NT
1.5.
‘Specimen’ means and includes stem cells obtained from umbilical cord blood and/or umbilical cord tissue individually or collectively.
1.6.
‘Collection Kit’ means the kit consisting of all essential materials required for the purpose of collection and labeling of the Maternal Blood and Specimen.
2.
SERVICES: OPTION AND FEES
2.1.
LifeCell offers its umbilical cord banking services under different plans, fees and payment methods as detailed in Exhibit 2, which the Client must choose at the time of Enrollment by completing the Exhibit 2.
2.2.
Client may also choose to subscribe for additional services as listed in Exhibit 2 and pay the additional fees.
2.3.
All applicable taxes including but not limited to service tax is payable by the Client.
3.
CLIENT RESPONSIBILITIES
3.1.
Prior to the birth of the Child, the Client must complete all the applicable Exhibits [1 to 8] and make due payment of fees. If surrogate, egg donor or sperm was used, each must fill out Exhibit 3.
President, LifeCell International
4.2
LifeCell has the option to relocate the Specimen and will provide notice to Client within 60 days of relocation.
5.
TERM OF AGREEMENT
5.1.
If the Client signs-up for the Annual Storage Plan, this Agreement will continue for one year from the date of birth of the Child (renewal date) and will automatically renew for successive one year period until the Child attains the age of 21 Years. This automatic renewal is subject to the Client paying the annual storage fee on or before the renewal date every year.
5.2.
If the Client signs-up for 21-Year Storage Plan, this Agreement will continue for twenty one (21) years from the date of birth of the Child.
5.3.
At least three (3) months before the expiration of the 21 year period, LifeCell shall intimate the Client (and/or Child in case the Child has come of Age) regarding the expiry of the Agreement, along with terms for continued storage. Accordingly the Client or Child can enter into a new Agreement and continue the storage.
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 11 of 24
6.
REPRESENTATIONS AND WARRANTIES OF CLIENT
8.4.
Disaster Relief: If the Client, Child, or Child’s sibling is diagnosed after the enrolment date for a hematological condition treatable by stem cell transplantation and should for any unforeseen reason that is beyond the reasonable control of LifeCell which may potentially deteriorate or cause loss of the Specimen during transit or processing or storage, LifeCell will use its best endeavors to find a unit of suitable match (as confirmed by the transplant physician) within 30 days failing which pay the Client Rs. 1,000,000 (Rupees One Million Only).
8.5.
Quality Guarantee: If the Client, Child or Child’s sibling is diagnosed after the enrolment date for a hematological condition treatable by stem cell transplantation and should for any reason the Specimen upon retrieval not meet LifeCell's then prevailing viability criteria benchmarked against existing international best practices, LifeCell will use its best endeavors to find a unit of suitable match (as confirmed by the transplant physician) within 30 days failing which pay the Client Rs. 1,000,000 (Rupees One Million Only).
8.6.
Worldwide Shipment Guarantee: There is no fee payable by the Client to LifeCell for retrieval of Specimen, including any additional testing related to release of Specimen for transplant. The Specimen will be available for delivery within 7 days or 90 days if cellular expansion is required. In the event of a transplant upon Client’s request LifeCell shall arrange and pay for X-free transport of the Specimen under cryogenic conditions to any destination worldwide.
Client represents and warrants that 6.1.
She / he is the parent or legal guardian to the Child.
6.2.
Client has had the opportunity to read, understand, review and consult with the Client's own legal counsel and medical professional, this Agreement, its Exhibits, possible risks of collection, processing, storage and possible future use of the Specimen.
6.3.
The decision to collect the Specimen and Maternal Blood, test the Maternal Blood and process and store the Specimen is a completely voluntary act of Client.
7.
RIGHTS TO SPECIMEN
7.1.
The Client shall have control over the Specimen until the Child attains majority, further to which all rights shall be automatically transferred to the Child.
7.2.
If there is a disagreement between parents the Mother’s wish shall prevail.
7.3.
The Client undertakes to inform the Child promptly of his/her right with regards to the Specimen on the Child attaining majority, including the right to renew this Agreement.
8.
LIFECELL CLIENT BENEFIT PROGRAMS
CLIE
PY O C NT
LifeCell understands the Client’s need to enhance the value of their investment and also provide a comprehensive coverage for their Child. Therefore LifeCell through its Client Benefit Programs provides additional guarantees, insurances, and benefits which are detailed below: 8.1.
8.2.
8.3.
Medical Insurance: If the Client, Child or Child’s sibling is diagnosed after the enrolment date for a hematological condition treatable by stem cell transplantation the Client under the LifeCell Cares Program can avail up to Rs. 1,000,000 (Rupees One Million only) to offset transplant related expenses including but not limited to procurement of an additional unit from any public cord blood registry worldwide. Storage Insurance: In case of demise of the earning member of the family, LifeCell would continue storage of the Specimen at LifeCell’s own cost for the remaining term of the Agreement (for clients who have chosen the 21-Year Storage Plan, LifeCell would issue a pro-rated refund the storage fees). Entitlement to Full Refund: LifeCell understands that the life and health of the Mother and Child are the utmost priority. In the event the Specimen is not collected due to this priority, LifeCell shall refund all fees paid by Client to LifeCell upon sharing of relevant declaration from the attending gynecologist.
President, LifeCell International
8.7.
Stem Cell Expansion Guarantee: In the event of a transplant of umbilical cord tissue stem cells LifeCell shall at its own cost expand and provide upto 500 million mesenchymal stem cells.
8.8.
Medical Concierge: For all medical and travel information relating to stem cell transplant using the stored specimen for the Baby or his/her immediate family members, LifeCell will ensure to provide, at no extra cost to the Client, the relevant information regarding leading transplant physicians, approved and credible medical transplant institutions including medical travel information relating to the Baby along with his/her immediate family members.
8.9.
General conditions for LifeCell Client Benefit Programs:
a) b) c)
The Client Agreement is valid and is in force. Payments would be made within 30 days on appropriate verification of Client’s request by LifeCell. In case of retrievals for transplant the Client has to submit duly filled up Retrieval Form (to be accompanied by Transplant Physician’s Certificate confirming end use in statutorily compliant transplant procedures).
9.
LIFECELL ASSURANCE LifeCell hereby assures that:
9.1.
LifeCell shall obtain all statutory permissions and licenses that are required for providing the services contemplated under this Agreement.
Client's Initials
Husband's Initials
Birth Mother, if not Client
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9.2.
LifeCell will provide the Client with the following immediately upon enrollment a Collection Kit compliant with International Air Transport Association [IATA] regulations, and a unique Client Relationship Management (CRM) number that enables the Client to quote for all communications with LifeCell.
9.3.
At the request of the Client, LifeCell would arrange and pay for qualified Phlebotomist for the collection of Maternal Blood and Specimen, and/or a certified Service Provider for X-Ray free transport of the Maternal Blood and Specimen to LifeCell’s Laboratory, provided however that the Client provides reasonable notice (not less than two hours prior to childbirth) to LifeCell for allowing the LifeCell arranged Phlebotomist to reach the venue of childbirth.
9.4.
Upon receipt of the Maternal Blood and Specimen LifeCell would determine whether it is fit or unfit for testing, processing and / or storage.
9.5.
In any event of Specimen found to be unfit, including but not limited to insufficient volume, low cell count / viability, positive screening of infectious diseases, microbial contamination of Specimen, etc., LifeCell will notify the Client immediately and seek instructions for disposal of the Specimen. If LifeCell does not receive written instructions within 30 days of such intimation then LifeCell shall continue storing the Specimen as is where is, however the benefits available under LifeCell Client Benefit Programs as per clause 8 shall not be applicable.
9.6.
9.7.
LifeCell disclaims any responsibility to provide any other services and third party service providers like Phlebotomist, Transporter, etc shall have the respective liability for their services including loss, damage, delay in delivery, etc.
10.3.
Client agrees that LifeCell‘s liability for any loss, harm, damage or claim of any kind in connection with this agreement or the services provided by LifeCell shall be limited to the return of an amount equal to all fees paid by Client to LifeCell or benefits available under the applicable LifeCell Client Benefit Programs (whichever is higher), except for acts committed by LifeCell that are intentional and/or grossly negligent.
11.
FORCE MAJEURE Client agrees that LifeCell’s liability for causes or circumstances which are beyond LifeCell’s reasonable control shall be limited to that committed under the “Disaster Relief” program.
12.
TERMINATION OF AGREEMENT
12.1.
This Agreement may be terminated
a)
by Client at any time prior to collection of Specimen, or
b)
by Client or Child (on attaining majority) at any time prior to the retrieval of the Specimen, or
c)
by LifeCell if it has exercised its right to refuse Specimen processing and / or storage for any reason, including the consequential act of sample rejection as per clause 9.5, or
d)
by LifeCell if any payment due to LifeCell is not timely paid and such failure to pay is not cured within 30 days after receipt of notice from LifeCell of such failure to pay, without prejudice to LifeCell’s right to take legal steps to recover the debt. Or
e)
by mutual agreement of Client and LifeCell, or
PY O C NT
In the event of Maternal Blood found to be unfit or not provided LifeCell will notify the Client immediately and seek another collection. If the Maternal Blood is not provided within 7 days of childbirth the Specimen can be used only for autologous purposes.
CLIE
10.2.
The Specimen would be tested, processed and stored in accordance to approved Standard Operating Procedures and in compliance with statutory regulations.
9.8.
The Specimen would be cryopreserved at its licensed facilities throughout the term of this Agreement.
f)
by either party upon 60 days prior written notice to the other party hereto, or
9.9.
Upon successful collection, processing and storage, LifeCell will provide the Client with a Preservation Certificate confirming successful storage of the Specimen along with sample storage details and test results.
g)
in the event the Specimen is retrieved for a transplant. However, if the Client retrieves only a portion of the Specimen, the Agreement would survive along with all benefits for the term of the agreement.
9.10.
The Specimen will be marked and referred to only by the CRM number and shall not directly refer to the Client or Child. Personal Identifiable Data of the Client or Child will not be disclosed to any third party without express written permission.
h)
in the event, the Specimen is lost or destroyed for reasons beyond LifeCell’s control.
i)
in the event either law or a governmental agency or regulatory provisions or medical guidelines require us to terminate the Agreement.
12.2.
Effects of Termination:
a)
If the Agreement is terminated under Section 12.1.(a) only the Processing and Storage Fees would be refunded.
b)
If the Agreement is terminated under Section 12.1.(b) all fees paid by the Client to LifeCell are non-refundable.
10.
DISCLAIMER & LIMITATIONS:
10.1.
LifeCell does not perform any medical services, give any medical advice, or otherwise perform any service other than those expressly indicated in this Agreement. It disclaims all other representations, guarantees, warranties or assurances, express or implied.
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 13 of 24
c)
If the Agreement is terminated under Section 12.1.(c) the Storage and / or Processing Fees would be refunded as applicable.
d)
If the Agreement is terminated under Section 12.1.(d), Client relinquishes all rights in and to the Specimen and waives all claims to the Specimen and LifeCell shall have the right at its sole discretion to dispose of the Specimen. However, LifeCell shall continue storing the Specimen with no liabilities to the Client for a period of two years from the date of termination. During this period the Client shall have the option of reviving the Agreement by paying all unpaid fees and a re-enrollment fee.
e)
If the Agreement is terminated by LifeCell under Section 12.1.(f), LifeCell shall at its own cost arrange for transfer of Specimen to a comparable stem cell bank facility and pay the new stem cell bank for storing the Specimen for the remaining period of the Agreement.
f)
If the Agreement is terminated under Sections 12.1.(e) or 12.1.(g) a pro-rated refund of the prepaid storage fees will be made by LifeCell to the Client.
g)
13.
All refunds by LifeCell shall be processed within 30 days of receiving the completed documentation.
GOVERNING LAW AND JURISDICTION
CLIE
MULTIPLE BIRTHS In the event of multiple births, if the Client desires to engage LifeCell to process, and store the cord blood and/or cord tissue for each Child, the Client must check the appropriate box on the Enrollment Form and pay the additional fees.
17.
ASSIGNMENT LifeCell may assign this Agreement to any individual or entity providing a similar service. If LifeCell is acquired by or merged with or into another company, LifeCell shall require that the terms of this Agreement continue in full force and effect. LifeCell shall notify the Client within 90 days in the event of any such assignment.
18.
NOTICE
18.1.
Notice to LifeCell must be in writing and delivered to LifeCell International Private Limited, #26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai – 600127.
18.2.
Notice to Client will be in writing and delivered to the address set forth in the Enrollment form or as updated by Client to LifeCell.
19.
ENTIRE AGREEMENT
PY O C NT
This Agreement is governed by, construed and interpreted in accordance with the laws of India. Courts in Chennai shall have exclusive jurisdiction. 15.
16.
ARBITRATION All disputes arising out of or relating to this Agreement will be resolved by arbitration. The arbitration will take place In Chennai, Tamilnadu, India. The Arbitration would be governed by the Arbitration and Conciliation Act, 1996.
14.
the Child hereby agrees to the release of information to the hospital, laboratory or physician providing the services to the Client.
This Agreement and the exhibits hereto constitute the entire agreement between LifeCell and Client and supersedes any prior agreements or understandings, oral and written. This Agreement may be modified only by written agreement of Client and Authorised Signatory of LifeCell.
20.
All provisions which by their terms require performance after the termination of this Agreement will survive the termination of this Agreement
CONFIDENTIALITY; CONSENT TO RELEASE LifeCell acknowledges the confidential nature of the Information provided to it and agrees to use its best efforts to maintain the confidentiality of the information except as required by law or as permitted by this Agreement. All conf idential information and personal identif iable information shall be kept on secure database with adequate backup measures. Client and, if different, the Birth Mother of
SURVIVAL
21.
SEVERABILITY If any part of this Agreement is found to be invalid or unenforceable, such provision is deemed modified to the extent necessary to make the Agreement enforceable, and this Agreement shall otherwise remain in full force and effect.
I ACCEPT ALL TERMS AND CONDITIONS OF THIS AGREEMENT
Name and Signature of Father/Legal Guardian
Name and Signature of Mother/Legal Guardian
Name of Birth Mother if not Client Signature of Birth Mother if not Client Date:
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 14 of 24
CRM NO.:
EXHIBIT - 3: MATERNAL HEALTH HISTORY (GENETIC MOTHER) The following questions are required for determination of donor-eligibility, and have not been developed by LifeCell. We understand that there may be sensitivities to some of the questions, and apologize for the inconvenience. LifeCell has made an effort to modify these questions from those published and required by the AABB (Formerly the American Association of Blood Banks) to minimize your discomfort. YES NO 1.
Do you currently have or have a history of any medical condition that could affect the collection or use of the stem cells such as,
a)
Cancer, Diabetes, Hepatitis, Blood Disease, Bleeding problem, Heart Disease, Drug or Alcohol abuse
b)
HIV/AIDS or a positive test for the HIV/AIDS virus, HTLV, Malaria, Chaga's disease.
c)
Stroke, Seizure or multiple sclerosis, Lung disease, Kidney disease, Liver disease, Babesiosis, Genetic disorder.
2.
Do you currently have or are you being treated for any type of infection?
3.
Do you have, or have a family history of, Dementia, degenerative or neurological disease, or Creutzfeld Jakob disease?
4.
In the past 6 months have you received a bite from an animal suspected of Rabies?
5.
Have you been treated for a sexually transmitted disease in the last 12 months?
6.
In the past 12 months have you had any immunizations, tattoos, body piercing, an accidental needle-stick, or come into contact
with someone's blood, open wound, or small pox vaccination site and/or bandage? 7.
In the past 12 months have you been in Juvenile detention, lock-up, jail or prison for more than 72 hours?
8.
In the past 12 months have you lived with a person who has Hepatitis?
9.
Have you in the past 5 years taken intravenous drugs not prescribed by a physician?
10.
Have you in the past 5 years received compensation for sex?
11.
Have you ever received whole blood, blood factor products, blood derivatives, growth hormones, bone or skin graft, or a tissue, organ (either human or animal), dura mater or bone marrow transplant?
12.
Have you in the past 12 months had intimate contact with a male who has ever had sexual contact with another male, anyone, who has HIV/AIDS or a positive test for HIV/AIDS virus, anyone who has hepatitis or anyone described in questions 9, 10 or 11?
13.
From 1980 through 1996 have you
a.
Spent 3 months or more cumulatively in the United Kingdom? If so, what city and country?
b.
Resided at a US military base in Europe for 6 months or more cumulatively? If so, what city and country?
14.
From 1980 to present have you spent 5 years or more in Europe cumulatively? If so, what city and country?
15.
Have you ever been diagnosed or suspected of having an acute respiratory disease such as (but not limited to) West Nile Virus, SARS, or Tuberculosis?
16.
In the past 3 years have you been outside the Country of your current residence? If so, what city & country?
17.
Have you experienced any of the following conditions that can be signs or symptoms of HIV/AIDS?
a.
Unexplained weight loss or night sweats?
b.
Blue or purple spots in your mouth or skin?
c.
Swollen lymph nodes for more than one month?
d.
White spots or unusual sores in your mouth?
e.
Cough that wont go away or shortness of breath?
f.
Diarrhea that won't go away?
g.
Fever of more than 100.5 F for more than 10 days?
18.
Have you had significant exposure to any substance that may be transferred in toxic doses, such as lead, mercury and gold?
For LifeCell Medical Team use only Reviewed by:..................................................
President, LifeCell International
Date:...............................................................
Client's Initials
Signature:........................................................
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 15 of 24
CRM NO.:
EXHIBIT - 4: MATERNAL HEALTH HISTORY (NON-CLIENT BIRTH MOTHER) The following questions are required for determination of donor-eligibility, and have not been developed by LifeCell. We understand that there may be sensitivities to some of the questions, and apologize for the inconvenience. LifeCell has made an effort to modify these questions from those published and required by the AABB (Formerly the American Association of Blood Banks) to minimize your discomfort. YES NO 1.
Do you currently have or have a history of any medical condition that could affect the collection or use of the stem cells such as,
a)
Cancer, Diabetes, Hepatitis, Blood Disease, Bleeding problem, Heart Disease, Drug or Alcohol abuse
b)
HIV/AIDS or a positive test for the HIV/AIDS virus, HTLV, Malaria, Chaga's disease.
c)
Stroke, Seizure or multiple sclerosis, Lung disease, Kidney disease, Liver disease, Babesiosis, Genetic disorder.
2.
Do you currently have or are you being treated for any type of infection?
3.
Do you have, or have a family history of, Dementia, degenerative or neurological disease, or Creutzfeld Jakob disease?
4.
In the past 6 months have you received a bite from an animal suspected of Rabies?
5.
Have you been treated for a sexually transmitted disease in the last 12 months?
6.
In the past 12 months have you had any immunizations, tattoos, body piercing, an accidental needle-stick, or come into contact
with someone's blood, open wound, or small pox vaccination site and/or bandage? 7.
In the past 12 months have you been in Juvenile detention, lock-up, jail or prison for more than 72 hours?
8.
In the past 12 months have you lived with a person who has Hepatitis?
9.
Have you in the past 5 years taken intravenous drugs not prescribed by a physician?
10.
Have you in the past 5 years received compensation for sex?
11.
Have you ever received whole blood, blood factor products, blood derivatives, growth hormones, bone or skin graft, or a tissue, organ (either human or animal), dura mater or bone marrow transplant?
12.
Have you in the past 12 months had intimate contact with a male who has ever had sexual contact with another male, anyone, who has HIV/AIDS or a positive test for HIV/AIDS virus, anyone who has hepatitis or anyone described in questions 9, 10 or 11?
13.
From 1980 through 1996 have you
a.
Spent 3 months or more cumulatively in the United Kingdom? If so, what city and country?
b.
Resided at a US military base in Europe for 6 months or more cumulatively? If so, what city and country?
14.
From 1980 to present have you spent 5 years or more in Europe cumulatively? If so, what city and country?
15.
Have you ever been diagnosed or suspected of having an acute respiratory disease such as (but not limited to) West Nile Virus, SARS, or Tuberculosis?
16.
In the past 3 years have you been outside the Country of your current residence? If so, what city & country?
17.
Have you experienced any of the following conditions that can be signs or symptoms of HIV/AIDS?
a.
Unexplained weight loss or night sweats?
b.
Blue or purple spots in your mouth or skin?
c.
Swollen lymph nodes for more than one month?
d.
White spots or unusual sores in your mouth?
e.
Cough that wont go away or shortness of breath?
f.
Diarrhea that won't go away?
g.
Fever of more than 100.5 F for more than 10 days?
18.
Have you had significant exposure to any substance that may be transferred in toxic doses, such as lead, mercury and gold?
For LifeCell Medical Team use only Reviewed by:..................................................
President, LifeCell International
Date:...............................................................
Client's Initials
Signature:........................................................
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 16 of 24
EXHIBIT - 5: CONSENT OF NON-CLIENT BIRTH MOTHER FOR COLLECTION: The undersigned Birth Mother of the Child has reviewed the above processing, Storage and Informed Consent Agreement (the Agreement”), and hereby acknowledge and agrees that she is not the legal guardian of the Child, is not a party to the agreement, and is not a third-party beneficiary of the Agreement. Birth Mother hereby waives, releases and abandons any and all rights or entitlement to the Umbilical cord Specimen, Maternal Blood Specimen, and Menstrual Blood Specimen. Birth mother consents and agrees to the testing of the Maternal Blood Specimen as referenced in the agreement and in Exhibit 7 of this agreement and consents and agrees to the release of the test results to the Client. Birth Mother agrees she has no right to enforce any term, condition or provision of the Agreement, or to exercise any right of the Client under the Agreement. Birth Mother acknowledges that Birth Mother has been fully informed of the procedures associated with cellular donation and the alternatives to cellular donation and accepts and agrees to the benefits, limitatations, risks, and discomfort of cellular donation and has had the opportunity to access donor advocacy service. Birth Mother has been given the Opportunity to ask questions and had those questions answered satisfactorily. Birth Mother assumes all risks associated with the collection of the Specimen, including the Maternal Blood Specimen.
EXHIBIT - 6: INFORMED CONSENT TO INFECTIOUS DISEASE & HIV TESTING LifeCell requires infectious disease testing to be done on the maternal blood that includes HIV testing, in conjunction with the processing of cord blood samples. The costs of these screening tests are included in the initial fee. The maternal blood sample must be drawn at the time of delivery independent of previous infectious disease/HIV testing which may have been done during pregnancy. I understand, if the volume of the maternal blood sample is insufficient or missing, a fresh sample of maternal blood will be drawn within 7 days of delivery. If the sample is not drawn the Specimen will automatically be quarantined, which may affect its status for transplant use. Screening for Infectious Diseases: I am aware that my blood will be screened for transfusion transmitted infections. The screening procedure involves testing of my blood for Syphillis, Hepatitis B, Hepatitis C, HIV, Cytomegalovirus, and Malaria. If any of these tests is positive, a confirmatory test is performed by an approved external agency and only if the confirmatory test is positive, then further course is decided with counselling. The results will not be disclosed to any other party without consent, except to the extent disclosure is required by law.
EXHIBIT - 7: AUTHORIZATON TOCOLLECT CORD BLOOD: RELEASE FROM LIABILITY The undersigned is participating in BabyCord program. The program requires the collection of umbilical cord blood at the time of birth of the Child. The collection procedure is outlined in BabyCord umbilical cord blood Collection Instructions. Consent is hereby granted by the undersigned to the medical professionals attending to the birth to perform the collections. The undersigned acknowledges that complications may occur during collection of umbilical cord blood which could prevent or impede the collection of the cord blood or procedure an inadequate Specimen. The undersigned further acknowledge that medical judgment, with the best interest of the mother and Child in mind, could totally prevent the collection. The undersigned hereby releases and forever discharges LifeCell, the obstetrician or certified nurse midwife, the hospital or birthing center, and their respective officers, directors, shareholders, employees, agents, representatives, affiliates, successors and assigns (collectively, the “Released Parties”) of and from any and all liability for any and all loss, harm, damage or claim of any kind arising from or relating to the collection of, or failure to collect, the cord blood. The undersigned acknowledges that, by this release, the undersigned is giving up any right she may otherwise have, now or in the future, to sue or otherwise seek monetary damages or other relief against any of the Released Parties for any reason relating to the collection of, or failure to collect, the cord blood. I have read the above information and hereby give the consent to perform the above required tests. Name of the Client …….......................................................................
Client’s Signature ..............................................
Name of the Husband ……...............................................................
Husband’s Signature .............................................
Obstetrician / Gynaecologist Name …………….......................................................................................................................................
Date …………………….........................................
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 17 of 24
EXHIBIT - 8: RISKS RELATING TO STEM CELL BANKING Stem cell banking has several inherent risks which may relate to collection, processing, testing, storage, and usage of the stem cells. The relevant risks in each of these areas are described below to enable better decision making by Clients. It has to be noted that these risks are by no means comprehensive and are only indicative. COLLECTION RISKS Collection of sample is usually done after clamping of the umbilical cord and separation of the mother and child and hence poses no risks to either one. However inherent risks of microbial contamination of sample present in the birth canal may render the sample unfit for storage. Certain circumstances or complications during delivery may entirely prevent the collection of sample or collection of adequate quantity of sample required for storage purposes. Client understands that engagement of trained personnel well in advance and handing over the collection kit to them at the time of reaching the place of delivery are critical to increasing the chances of successful sample collection. Further the birth mothers by law required to screened and tested for infectious diseases using peripheral venous blood. This collection is maternal blood may cause discomfort, possible bruising and swelling around the puncture site; rarely an infection; and uncommonly, faintness from the procedure. Client assumes all risks involved in collection of maternal blood, and also understands that if any of the results of infectious diseases testing is positive then LifeCell may decline to continue storing the sample. TESTING RISKS The samples are tested for reporting of the identity and quality of sample, based on the results of which a decision is taken on transplantation upon eventual need. LifeCell through extensive use of automated, bi-directionally interfaced, bar-coded sample handling,
and in-house testing, that helps reduce the chances of errors; active participation in proficiency testing programs; and maintenance of accreditation from reputed institutions provides Clients the assurance they seek on the reported results. However errors may happen in the pre-analytic, analytic, and post-analytic phases of testing due to systems, processes, and procedures involved in the transmission and reporting of test results. Client understands if in doubt that they have the opportunity of seeking external testing at their own costs to reconfirm the results reported by LifeCell, for which LifeCell would offer its fullest cooperation. STORAGE RISKS Long-term storage of samples could be associated with risks of either loss of viability, transmission of infectious diseases; partial or total loss due to reasons beyond reasonable control of LifeCell. However no assurance can be provided on the maintenance of viability for indefinite storage, and that the sample may also be lost due to equipment failure and / or accident which may render the sample unfit for transplantation. By placing the samples with bar-codes in overwrap bags and metal canisters where applicable; maintenance of samples in vapor phase nitrogen; and placement high-risk/ quarantine samples in a separate vessel help avoid the chances of cross-contamination. Also maintenance of adequate nitrogen levels in the vessels through piped supply from bulk tanks for automated top-ups; provision of continuous monitoring and automated alarm systems onto storage vessels, and supply with triple layer supply of electricity (power grid, uninterrupted power supply, and diesel generator) minimize chances of temperature deviations which may result in loss of viability. Adequate facility design considerations, running of regular stability testing programs, maintenance of insurance covers in accordance to the risks, and procedures for safety and emergency handling also help in providing added confidence. TRANSPORTATION RISKS Transport from the place of childbirth to the LifeCell laboratory, or transport from LifeCell laboratory to the transplant center has to be done within a reasonable period of time for minimizing loss of viability. However due to disruptions in flight or other transport operations, nonmaintenance of temperature due to poor refrigeration of foam bricks or performance of the dry shippers, improper packaging due to nonfollowing of instructions provided, accidents, or theft, may cause the sample to be lost or delayed in reaching the destination. Utilization of certified collected and distribution kits designed to maintain a controlled environment for a reasonable period of time, maintenance of sample traceability at all times of transport, utilizing experienced courier companies which have x-ray waiver procedures, will help minimize these risks. Client understands that no guarantee can be provided by LifeCell or the courier company on the safe and timely transport, and that Client has the option of choosing the best possible mode of transport.
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 18 of 24
APPLICATION RISKS Umbilical cord blood, like bone marrow and peripheral blood, is rich in hematopoietic progenitor cells, and has been used in the treatment of a variety of inherited or acquired disorders, including hematologic malignancies, metabolic disorders, and immunodeficiencies. Umbilical cord tissue, like the bone marrow, is also rich in mesenchymal progenitor cells, and is potentially useful for several regenerative medicine applications which are currently under-investigation in several clinical trials around the world. However there is no guarantee of successful transformation of these trials into commercial applications. The quantity of cells required for transplant varies depending upon eventual use and/ or patient body weight. While techniques for expansion of umbilical cord blood stem cells have been promising there is no guarantee that these will be eventually successful. Client also understands that cells obtained from the umbilical cord tissue may need further processing before use. Client is aware that banking a Child’s sample does not guarantee that a stem cell transplant would be the first or best course of treatment for any particular disease or that a Child’s own stem cell is useful for every disease treatable by stem cell transplantation. A medical care provider ultimately decides whether the use of the Child’s sample is indicated, based on the nature and progression of the disease, and HLA matching between donor and recipient.
EXHIBIT - 9: LIST OF TESTS PERFORMED
Cord Blood:
Blood grouping & RH typing Total Nucleated Cell count Total Mononuclear Cell count
Total CD 34 Cell count CD 34 Stem Cell Viability Sterility
At retrieval for transplant
HLA Typing
CFU Assay
Maternal Blood:
Anti - HBC Anti - HCV CMV - IgG Syphilis Malaria Nucleic Acid test (HCV and HIV)
Cord Tissue:
Cell Proliferation Assay Cell Morphology
Viable Cell count Gram Staining
At retrieval for transplant
Viability Flow Marker CD 105 Sterility Mycoplasma
Flow Marker CD 90 Flow Marker CD 31 Endotoxin HLA testing
Menstrual Blood:
Total Nucleated Cell count Cell Morphology
Viable Cell count Gram Staining
At retrieval for transplant
Viability Flow Marker CD 105 Sterility Mycoplasma
Flow Marker CD 90 Flow Marker CD 31 Endotoxin HLA testing
President, LifeCell International
CMV - IgM HBSAg HIV I/II Blood grouping & RH typing HTLV I/II
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 19 of 24
AGE P S I TH
TI N E T N IS I
NK A L B LEFT Y L L ONA
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 20 of 24
APP. NO. ........................................... CRM NO.
LifeCell International Private Limited Regd. Office: 26, Vandalur-Kelambakkam Road, Keelakotaiyur, Chennai - 600 127 TEMPORARY RECEIPT Receipt No: ..................................................
Date:
Received with thanks from Mr./Ms. .............................................................................................................. towards enrollment vide APP.No. ...........................................................................................a sum of Rs.....................................................................................................................................................Only) towards Enrollment/Processing/Storage fees by way of Cash/Credit Card/*Cheque/ *DD /EFT No. Date.............................Drawn on............................ Branch...................................... City.................................. Plan No. : .......................................................................................... Plan Name:......................................................................................... EDD:................................................................................................. *Cheque/DD Subject to realization
Note : A computer generated “Receipt” will be sent along with the Preservation certificate For LifeCell use only
For LifeCell International Private Limited
Computer Receipt No :
N E I L C
Y P O TC
Authorised Signatory
For LifeCell use only Payment received by
:
..............................................
Designation
:
..............................................
Center
:
..............................................
Center’s Tel. No.
:
..............................................
TOLL FREE
:
1800 - 419 - 5555 (Name of the center incharge)
Signature of the center incharge
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 21 of 24
AGE P S I TH
BLA T F E LY L L A N TIO N E T IS IN
NK
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 22 of 24
APP. NO. ........................................... CRM NO.
LifeCell International Private Limited Regd. Office: 26, Vandalur-Kelambakkam Road, Keelakotaiyur, Chennai - 600 127 TEMPORARY RECEIPT Receipt No: ..................................................
Date:
Received with thanks from Mr./Ms. .............................................................................................................. towards enrollment vide APP.No. ...........................................................................................a sum of Rs.....................................................................................................................................................Only) towards Enrollment/Processing/Storage fees by way of Cash/Credit Card/*Cheque/ *DD /EFT No. Date.............................Drawn on............................ Branch...................................... City.................................. Plan No. : .......................................................................................... Plan Name:......................................................................................... EDD:................................................................................................. *Cheque/DD Subject to realization
Note : A computer generated “Receipt” will be sent along with the Preservation certificate For LifeCell use only
For LifeCell International Private Limited
Computer Receipt No :
EL C E LIF
PY O C L
Authorised Signatory
For LifeCell use only Payment received by
:
..............................................
Designation
:
..............................................
Center
:
..............................................
Center’s Tel. No.
:
..............................................
TOLL FREE
:
1800 - 419 - 5555 (Name of the center incharge)
Signature of the center incharge
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 21 of 24
AGE P S I TH
TI N E T IS IN
NK A L B EFT L Y L ONAL
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com Page 24 of 24
AGE P S I TH
TI N E T IS IN
BLA T F E YL L L A ON
NK
LifeCell International Pvt Ltd, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 127 | 044 4744 5353 | www.lifecellinternational.com
BC/EFCA/Jun 13/Bajaj/V-009 TOLL FREE: 1800 - 419 - 5555 | SMS ‘BABYCORD’ TO 53456 | www.lifecellinternational.com LifeCell International Private Limited, 26, Vandalur Kelambakkam Main Road, Keelakotaiyur, Chennai - 600 127 Phone: +91 44 4744 5353 | email: contactus@lifecell.in