800 LIFECELL TOLL FREE: | HELPLINE: +971 44494067| EMAIL: contactus@lifecellinternational.com| www.lifecellinternational.com 800 54332355 LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE.
EFCA/INT/BC/Jan 12/V-001
Client Enrollment Form & 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 *Client's Name Husband's Name Client's Date of Birth
Communication Address
Thank you Stem Cells I’m here because of you!
Landmark City
State
Country
PO Box
Telephone (Home) Country Code
Telephone Number
Mobile 1
Mobile 2 Country Code
Mobile Number
Mobile Number
E-mail ID If Permanent Address is same as Communication Address (Tick) Permanent Address (If different from above)
Landmark City
State
Country
PO Box
Identity Proof
Husband
Client
Identification provided
Passport
Driving Licence
National ID
Other
Client's Initials
Husband's Initials
If ‘Other’, please specify ID Proof No.
If you are an existing LifeCell Client, provide 12 digit CRM No.
* Parent or legal guardian of the Child.
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com Page 1 of 45
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 *Client's Name Husband's Name Client's Date of Birth
Communication Address
Thank you Stem Cells I’m here because of you!
Landmark City
State
Country
PO Box
Telephone (Home) Country Code
Telephone Number
Mobile 1
Mobile 2 Country Code
Mobile Number
Mobile Number
E-mail ID If Permanent Address is same as Communication Address (Tick) Permanent Address (If different from above)
Landmark City
State
Country
PO Box
Identity Proof
Husband
Client
Identification provided
Passport
Driving Licence
National ID
Other
Client's Initials
Husband's Initials
If ‘Other’, please specify ID Proof No.
If you are an existing LifeCell Client, provide 12 digit CRM No.
* Parent or legal guardian of the Child.
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com Page 1 of 45
APP. NO................................................ APP. NO................................................ CRM NO.
CRM NO. HOSPITAL & BIRTHING DETAILS
EMPLOYMENT DETAILS
Expected Date of Delivery
Type of Pregnancy (Tick)
Single Birth
Quads
Triplets
Twins
Employment
Husband
Client
Employment Type (Tick)
Service
Professional
Entrepreneur
Consulting Hospital / Clinic Organisation Obstetrician/ Gynaecologist
Designation
Communication Address
Office Address
Landmark
City
City
Country
State
Country
State
PO Box
PO Box
Telephone (Office) Country Code
Telephone Country Code
Telephone Number
STD Code
Telephone Number
E-mail ID
E-mail ID
SHIPMENT DETAILS
If Birthing center is same as consulting Gynaecologist (Tick) Birthing Center (if different from consulting Gynaecologist)
Sent Collection kit to (Tick)
Obstetrician/ Gynaecologist
Shipping Address
Communication Address
Permanent Address
Office Address
Hand over to Client in person
(if different from above)
Communication Address
Landmark City
Landmark City
State
Country
State
Country
PO Box
Pin Code Telephone Country Code
Telephone Country Code
Telephone Number
DETAILS OF REFERENCE
Mobile Country Code
Telephone Number
Mobile Number
If referred by an existing Client, please provide details as below:
E-mail ID
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.
Referring Client’s Name Referring Client’s CRM
Mobile / Phone
If referred by an Gynaecologist or Care Giver, please provide details as below: Signature of Client Name:
Signature of Birth Mother if not Client
Signature of Husband Name:
Referring Gynaecologist
Name:
Hospital
Date:
City
Mobile / Phone
For LifeCell use only
TICK AS APPLICABLE FOR LIFECELL SUPPORT SERVICE:
Name of LifeCell Executive LifeCell Authorised Signature Name of Signatory:
Requesting LifeCell to arrange for pick up of Maternal sample and Specimen Employee Code
Client's Initials
Husband's Initials
Client's Initials
Birth Mother, if not Client
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 2 of 45
Page 3 of 45
APP. NO................................................ APP. NO................................................ CRM NO.
CRM NO. HOSPITAL & BIRTHING DETAILS
EMPLOYMENT DETAILS
Expected Date of Delivery
Type of Pregnancy (Tick)
Single Birth
Quads
Triplets
Twins
Employment
Husband
Client
Employment Type (Tick)
Service
Professional
Entrepreneur
Consulting Hospital / Clinic Organisation Obstetrician/ Gynaecologist
Designation
Communication Address
Office Address
Landmark
City
City
Country
State
Country
State
PO Box
PO Box
Telephone (Office) Country Code
Telephone Country Code
Telephone Number
STD Code
Telephone Number
E-mail ID
E-mail ID
SHIPMENT DETAILS
If Birthing center is same as consulting Gynaecologist (Tick) Birthing Center (if different from consulting Gynaecologist)
Sent Collection kit to (Tick)
Obstetrician/ Gynaecologist
Shipping Address
Communication Address
Permanent Address
Office Address
Hand over to Client in person
(if different from above)
Communication Address
Landmark City
Landmark City
State
Country
State
Country
PO Box
Pin Code Telephone Country Code
Telephone Country Code
Telephone Number
DETAILS OF REFERENCE
Mobile Country Code
Telephone Number
Mobile Number
If referred by an existing Client, please provide details as below:
E-mail ID
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.
Referring Client’s Name Referring Client’s CRM
Mobile / Phone
If referred by an Gynaecologist or Care Giver, please provide details as below: Signature of Client Name:
Signature of Birth Mother if not Client
Signature of Husband Name:
Referring Gynaecologist
Name:
Hospital
Date:
City
Mobile / Phone
For LifeCell use only
TICK AS APPLICABLE FOR LIFECELL SUPPORT SERVICE:
Name of LifeCell Executive LifeCell Authorised Signature Name of Signatory:
Requesting LifeCell to arrange for pick up of Maternal sample and Specimen Employee Code
Client's Initials
Husband's Initials
Client's Initials
Birth Mother, if not Client
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 2 of 45
Page 3 of 45
EXHIBIT - 2
APP. NO. ........................................... CRM NO.
FEE SCHEDULE - GCC I wish to enrol for (Tick the appropriate preceeding box) UAE AED
Plan Name & Description
Qatar QAR
KSA SAR
Oman OMR
Bahrain BHD
Kuwait KWD
Others USD
BabyCord - 21 YEAR STORAGE PLAN ONE TIME PAYMENT
9,900
10,130
9,830
1,040
1,020
750
2,700
3 EMI
3,300
3,380
3,280
350
340
250
900
6 EMI
1,655
1,695
1,645
175
170
125
450
12 EMI*
840
860
835
90
85
65
230
BabyCord Duo - 21 YEAR STORAGE PLAN ONE TIME PAYMENT
11,990
12,380
12,015
1,270
1,245
915
3,300
3 EMI
4,000
4,130
4,005
425
415
305
1,100
6 EMI
2,005
2,070
2,010
215
210
155
550
12 EMI*
1,020
1,050
1,020
110
105
80
280
Protect baby, Protect Mom - 21 YEAR STORAGE PLAN ONE TIME PAYMENT
18,990
19,505
18,935
2,000
1,960
1,440
5,200
3 EMI
6,330
6,505
6,315
670
655
480
1,735
6 EMI
3,180
3,265
3,170
335
330
240
870
12 EMI*
1,610
1,655
1,605
170
165
120
440
BabyCord USA - 21 YEAR STORAGE PLAN ONE TIME PAYMENT
13,990
14,255
13,835
1,465
1,430
1,055
3,800
3 EMI
4,665
4,755
4,615
490
480
355
1,270
6 EMI
2,340
2,315
2,315
245
240
180
635
12 EMI*
1,185
1,210
1,175
125
120
90
320
*First two EMI’s should be paid in advance Optional service which can be combined with any of the above services
Value Added service
T
LEF Y L L NA
K BLAN
New Born Genetic Testing Guarantee to expand 500 Million Umbilical cord tissue s t em cells obtained from Child to be provided at the time of transplant.
TIO
AGE P S I TH
EN T N I S I
1,490
1,505
1,460
155
155
115
400
1,490
1,505
1,460
155
155
115
400
Description of Service BabyCord
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. Expansion upto 500 Million menstrual blood derived mesenchymal stem cells to be provided at the time of transplant.
BabyCord USA
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 at Cryo-Cell facility, USA.
I wish to enrol for (Tick)
BABYCORD
Payment Plan
21 year Storage
Value Added Service
Expansion Guarantee of 500 Million cord tissue stem cells during transplant
BABYCORD DUO
BABYCORD USA
PROTECT BABY, PROTECT MOM
3 EMI
6 EMI
12 EMI
New Born Genetic Testing
PAYMENT BY CREDIT CARD Credit Card mandate (to be filled-in by the Credit Card member)
Debit Cards are not accepted
Credit Card No.:
Amount to be charged
Card Expiry Date:
Type of card:
Currency:
Amount to be charged
Date of Effect
(Monthly Payments)
(Monthly Payments)
5th
21st Start Month
No. of EMIs
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 Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 6 of 45
Page 5 of 45
EXHIBIT - 2
APP. NO. ........................................... CRM NO.
FEE SCHEDULE - GCC I wish to enrol for (Tick the appropriate preceeding box) UAE AED
Plan Name & Description
Qatar QAR
KSA SAR
Oman OMR
Bahrain BHD
Kuwait KWD
Others USD
BabyCord - 21 YEAR STORAGE PLAN ONE TIME PAYMENT
9,900
10,130
9,830
1,040
1,020
750
2,700
3 EMI
3,300
3,380
3,280
350
340
250
900
6 EMI
1,655
1,695
1,645
175
170
125
450
12 EMI*
840
860
835
90
85
65
230
BabyCord Duo - 21 YEAR STORAGE PLAN ONE TIME PAYMENT
11,990
12,380
12,015
1,270
1,245
915
3,300
3 EMI
4,000
4,130
4,005
425
415
305
1,100
6 EMI
2,005
2,070
2,010
215
210
155
550
12 EMI*
1,020
1,050
1,020
110
105
80
280
Protect baby, Protect Mom - 21 YEAR STORAGE PLAN ONE TIME PAYMENT
18,990
19,505
18,935
2,000
1,960
1,440
5,200
3 EMI
6,330
6,505
6,315
670
655
480
1,735
6 EMI
3,180
3,265
3,170
335
330
240
870
12 EMI*
1,610
1,655
1,605
170
165
120
440
BabyCord USA - 21 YEAR STORAGE PLAN ONE TIME PAYMENT
13,990
14,255
13,835
1,465
1,430
1,055
3,800
3 EMI
4,665
4,755
4,615
490
480
355
1,270
6 EMI
2,340
2,315
2,315
245
240
180
635
12 EMI*
1,185
1,210
1,175
125
120
90
320
*First two EMI’s should be paid in advance Optional service which can be combined with any of the above services
Value Added service
T
LEF Y L L NA
K BLAN
New Born Genetic Testing Guarantee to expand 500 Million Umbilical cord tissue s t em cells obtained from Child to be provided at the time of transplant.
TIO
AGE P S I TH
EN T N I S I
1,490
1,505
1,460
155
155
115
400
1,490
1,505
1,460
155
155
115
400
Description of Service BabyCord
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. Expansion upto 500 Million menstrual blood derived mesenchymal stem cells to be provided at the time of transplant.
BabyCord USA
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 at Cryo-Cell facility, USA.
I wish to enrol for (Tick)
BABYCORD
Payment Plan
21 year Storage
Value Added Service
Expansion Guarantee of 500 Million cord tissue stem cells during transplant
BABYCORD DUO
BABYCORD USA
PROTECT BABY, PROTECT MOM
3 EMI
6 EMI
12 EMI
New Born Genetic Testing
PAYMENT BY CREDIT CARD Credit Card mandate (to be filled-in by the Credit Card member)
Debit Cards are not accepted
Credit Card No.:
Amount to be charged
Card Expiry Date:
Type of card:
Currency:
Amount to be charged
Date of Effect
(Monthly Payments)
(Monthly Payments)
5th
21st Start Month
No. of EMIs
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 Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 6 of 45
Page 5 of 45
EXHIBIT - 2
APP. NO. ........................................... CRM NO.
FEE SCHEDULE - GCC I wish to enrol for (Tick the appropriate preceeding box) UAE AED
Plan Name & Description
Qatar QAR
KSA SAR
Oman OMR
Bahrain BHD
Kuwait KWD
Others USD
BabyCord - 21 YEAR STORAGE PLAN ONE TIME PAYMENT
9,900
10,130
9,830
1,040
1,020
750
2,700
3 EMI
3,300
3,380
3,280
350
340
250
900
6 EMI
1,655
1,695
1,645
175
170
125
450
12 EMI*
840
860
835
90
85
65
230
BabyCord Duo - 21 YEAR STORAGE PLAN ONE TIME PAYMENT
11,990
12,380
12,015
1,270
1,245
915
3,300
3 EMI
4,000
4,130
4,005
425
415
305
1,100
6 EMI
2,005
2,070
2,010
215
210
155
550
12 EMI*
1,020
1,050
1,020
110
105
80
280
Protect baby, Protect Mom - 21 YEAR STORAGE PLAN ONE TIME PAYMENT
18,990
19,505
18,935
2,000
1,960
1,440
5,200
3 EMI
6,330
6,505
6,315
670
655
480
1,735
6 EMI
3,180
3,265
3,170
335
330
240
870
12 EMI*
1,610
1,655
1,605
170
165
120
440
BabyCord USA - 21 YEAR STORAGE PLAN ONE TIME PAYMENT
13,990
14,255
13,835
1,465
1,430
1,055
3,800
3 EMI
4,665
4,755
4,615
490
480
355
1,270
6 EMI
2,340
2,315
2,315
245
240
180
635
12 EMI*
1,185
1,210
1,175
125
120
90
320
155
115
400
155
115
400
*First two EMI’s should be paid in advance Optional service which can be combined with any of the above services
Value Added service
T
LEF Y L L NA
K BLAN
New Born Genetic Testing Guarantee to expand 500 Million Umbilical cord tissue s t em cells obtained from Child to be provided at the time of transplant.
TIO
AGE P S I TH
EN T N I S I
1,490
1,505
1,460
1,490
1,505
1,460
Y COP
T
N CLIE
Description of Service
155 155
BabyCord
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. Expansion upto 500 Million menstrual blood derived mesenchymal stem cells to be provided at the time of transplant.
BabyCord USA
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 at Cryo-Cell facility, USA.
I wish to enrol for (Tick)
BABYCORD
Payment Plan
21 year Storage
Value Added Service
Expansion Guarantee of 500 Million cord tissue stem cells during transplant
BABYCORD DUO
BABYCORD USA
PROTECT BABY, PROTECT MOM
3 EMI
6 EMI
12 EMI
New Born Genetic Testing
PAYMENT BY CREDIT CARD Credit Card mandate (to be filled-in by the Credit Card member)
Debit Cards are not accepted
Credit Card No.:
Amount to be charged
Card Expiry Date:
Type of card:
Currency:
Amount to be charged
Date of Effect
(Monthly Payments)
(Monthly Payments)
5th
21st Start Month
No. of EMIs
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 Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 6 of 45
Page 5 of 45
EXHIBIT - 2
APP. NO. ........................................... CRM NO.
FEE SCHEDULE - GCC I wish to enrol for (Tick the appropriate preceeding box) UAE AED
Plan Name & Description
Qatar QAR
KSA SAR
Oman OMR
Bahrain BHD
Kuwait KWD
Others USD
BabyCord - 21 YEAR STORAGE PLAN ONE TIME PAYMENT
9,900
10,130
9,830
1,040
1,020
750
2,700
3 EMI
3,300
3,380
3,280
350
340
250
900
6 EMI
1,655
1,695
1,645
175
170
125
450
12 EMI*
840
860
835
90
85
65
230
BabyCord Duo - 21 YEAR STORAGE PLAN ONE TIME PAYMENT
11,990
12,380
12,015
1,270
1,245
915
3,300
3 EMI
4,000
4,130
4,005
425
415
305
1,100
6 EMI
2,005
2,070
2,010
215
210
155
550
12 EMI*
1,020
1,050
1,020
110
105
80
280
Protect baby, Protect Mom - 21 YEAR STORAGE PLAN ONE TIME PAYMENT
18,990
19,505
18,935
2,000
1,960
1,440
5,200
3 EMI
6,330
6,505
6,315
670
655
480
1,735
6 EMI
3,180
3,265
3,170
335
330
240
870
12 EMI*
1,610
1,655
1,605
170
165
120
440
BabyCord USA - 21 YEAR STORAGE PLAN ONE TIME PAYMENT
13,990
14,255
13,835
1,465
1,430
1,055
3,800
3 EMI
4,665
4,755
4,615
490
480
355
1,270
6 EMI
2,340
2,315
2,315
245
240
180
635
12 EMI*
1,185
1,210
1,175
125
120
90
320
155
115
400
155
115
400
*First two EMI’s should be paid in advance Optional service which can be combined with any of the above services
Value Added service
T
LEF Y L L NA
K BLAN
New Born Genetic Testing Guarantee to expand 500 Million Umbilical cord tissue s t em cells obtained from Child to be provided at the time of transplant.
TIO
AGE P S I TH
EN T N I S I
1,490
1,505
1,460
1,490
1,505
1,460
Y COP
T
N CLIE
Description of Service
155 155
BabyCord
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. Expansion upto 500 Million menstrual blood derived mesenchymal stem cells to be provided at the time of transplant.
BabyCord USA
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 at Cryo-Cell facility, USA.
I wish to enrol for (Tick)
BABYCORD
Payment Plan
21 year Storage
Value Added Service
Expansion Guarantee of 500 Million cord tissue stem cells during transplant
BABYCORD DUO
BABYCORD USA
PROTECT BABY, PROTECT MOM
3 EMI
6 EMI
12 EMI
New Born Genetic Testing
PAYMENT BY CREDIT CARD Credit Card mandate (to be filled-in by the Credit Card member)
Debit Cards are not accepted
Credit Card No.:
Amount to be charged
Card Expiry Date:
Type of card:
Currency:
Amount to be charged
Date of Effect
(Monthly Payments)
(Monthly Payments)
5th
21st Start Month
No. of EMIs
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 Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 6 of 45
Page 5 of 45
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 Arabia FZ LLC, Suite 2621, Shatha Tower, Dubai Media City, PO Box 502026, Dubai, UAE (‘LifeCell’), 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 on the following terms (this ‘Agreement’). This Agreement is entered into this _________ day of ___________________, 201______ (the ‘Enrollment Date’) and legally binds LifeCell and the Client, including the birth mother of the Child.
1. Definitions: In this Agreement, (including the recitals above), unless the context otherwise requires, the following expressions shall have the following meanings:
K
LLY L
NA
IS E G A P THIS
TIO N E T N I
LAN B T F E
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.
‘Birth Mother’ means the one who has borne the child in her womb.
1.4.
‘Genetic Mother’ if different from the Birth Mother means the mother from whom the egg has been obtained.
1.5.
‘Caregiver’ means the Obstetrician / Gynaecologist or qualified medical professional / midwife who will be assisting in delivering the Child.
1.6.
1.7.
1.8.
‘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. ‘Specimen’ means and includes stem cells obtained from umbilical cord blood and /or umbilical cord tissue individually or collectively. ‘Collection Kit’ means the kit consisting all essential materials required for the purpose of collection and labeling of the Maternal Blood and Specimen, such as Cord Blood Collection Bag, Cord Tissue Collection Containers, Barcode labels, Vacuum Test Tubes, Foam Bricks, Alcohol Swabs, Hologram Stickers, Maternal Blood and Specimen Collection and Packing Instructions, Sealable Plastic Bags and Absorbent Paper Towels, and all
President, LifeCell International
packed in a certified transport container compliant with International Air Transport Association (IATA) regulations. 1.9.
‘LifeCell Laboratory’ means LifeCell's licensed and accredited laboratory facilities where the Specimen is processed, tested, and/or stored at Cryo-Cell laboratory, USA at the option of the Client as per the chosen plan.
1.10.
‘Minimally Manipulated Stem Cells’ means stem cells that have not been subjected to ex- vivo procedure such as expansion of cell populations, genetic alterations, etc.
1.11.
‘Minimally Expanded Stem Cells’ means cells that have been obtained from ex-vivo isolation and not subjected to further passaging.
1.12.
‘Hematopoietic Stem Cells’ means multipotent stem cells that are characterized by the expression of the marker CD34.
1.13.
‘Mesenchymal Stem Cells’ means multipotent stem cells that can differentiate into a variety of cell types and are characterized by expression of the markers CD90 and CD105.
1.14.
‘Sibling’ means a brother or sister of the Child having one or both parents in common.
2.
Services of LifeCell; Testing, Processing, Preserving and Storage.
2.1.
LifeCell offers its services under various options which the Client must choose from as detailed in Exhibit 2,
2.2.
LifeCell shall obtain all statutory permissions and licenses that might be required for providing the services contemplated under this Agreement.
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 8 of 45
Page 9 of 45
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 Arabia FZ LLC, Suite 2621, Shatha Tower, Dubai Media City, PO Box 502026, Dubai, UAE (‘LifeCell’), 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 on the following terms (this ‘Agreement’). This Agreement is entered into this _________ day of ___________________, 201______ (the ‘Enrollment Date’) and legally binds LifeCell and the Client, including the birth mother of the Child.
1. Definitions: In this Agreement, (including the recitals above), unless the context otherwise requires, the following expressions shall have the following meanings:
K
LLY L
NA
IS E G A P THIS
TIO N E T N I
LAN B T F E
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.
‘Birth Mother’ means the one who has borne the child in her womb.
1.4.
‘Genetic Mother’ if different from the Birth Mother means the mother from whom the egg has been obtained.
1.5.
‘Caregiver’ means the Obstetrician / Gynaecologist or qualified medical professional / midwife who will be assisting in delivering the Child.
1.6.
1.7.
1.8.
‘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. ‘Specimen’ means and includes stem cells obtained from umbilical cord blood and /or umbilical cord tissue individually or collectively. ‘Collection Kit’ means the kit consisting all essential materials required for the purpose of collection and labeling of the Maternal Blood and Specimen, such as Cord Blood Collection Bag, Cord Tissue Collection Containers, Barcode labels, Vacuum Test Tubes, Foam Bricks, Alcohol Swabs, Hologram Stickers, Maternal Blood and Specimen Collection and Packing Instructions, Sealable Plastic Bags and Absorbent Paper Towels, and all
President, LifeCell International
packed in a certified transport container compliant with International Air Transport Association (IATA) regulations. 1.9.
‘LifeCell Laboratory’ means LifeCell's licensed and accredited laboratory facilities where the Specimen is processed, tested, and/or stored at Cryo-Cell laboratory, USA at the option of the Client as per the chosen plan.
1.10.
‘Minimally Manipulated Stem Cells’ means stem cells that have not been subjected to ex- vivo procedure such as expansion of cell populations, genetic alterations, etc.
1.11.
‘Minimally Expanded Stem Cells’ means cells that have been obtained from ex-vivo isolation and not subjected to further passaging.
1.12.
‘Hematopoietic Stem Cells’ means multipotent stem cells that are characterized by the expression of the marker CD34.
1.13.
‘Mesenchymal Stem Cells’ means multipotent stem cells that can differentiate into a variety of cell types and are characterized by expression of the markers CD90 and CD105.
1.14.
‘Sibling’ means a brother or sister of the Child having one or both parents in common.
2.
Services of LifeCell; Testing, Processing, Preserving and Storage.
2.1.
LifeCell offers its services under various options which the Client must choose from as detailed in Exhibit 2,
2.2.
LifeCell shall obtain all statutory permissions and licenses that might be required for providing the services contemplated under this Agreement.
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 8 of 45
Page 9 of 45
2.3
LifeCell will provide the Client with the following immediately upon enrollment:
labeling of the Maternal Blood and the Specimen for delivery to LifeCell, in accordance to the instructions provided by LifeCell. The Client or the authorized representative of the Client shall also ensure that the forms included in the Collection Kit are duly filled up and sent to LifeCell.
2.3.1. A Collection Kit 2.3.2. A copy of this Agreement 2.3.3. A unique Client Relationship Management (CRM) identification number that enables the Client to quote for all communications with LifeCell. 2.4.
2.6.
2.7.
LifeCell at the request of the Client would arrange for pick-up of the Maternal Blood and Specimen from the Hospital / Birthing center to LifeCell Laboratory, using a certified Service Provider who has the required expertise in the correct handling and transportation of such Maternal Blood and Specimen at no additional costs to the Client. The Service Provider is not an agent of LifeCell and LifeCell shall not be responsible in any manner for the services rendered by the Service Provider. 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 including but not limited to cell counts, sterility, viability, and infectious disease screening for Syphilis, Malaria, Hepatitis B, Hepatitis C, Human Immunodeficiency Virus, and Cytomegalovirus. In the event that the Specimen is determined by LifeCell to be unfit for processing and / or storage for any reason, such as insuf ficient volume, low cell count / viability, positive screening of infectious diseases, microbial contamination of Specimen, etc., then LifeCell will notify the Client immediately, and seek instructions for disposal of the Specimen. If LifeCell does not receive written instructions within 60 days of such notice then LifeCell has the right to terminate the Agreement and destroy the Specimen without further liability.
3.
Client Responsibilities.
3.1.
Prior to the birth of the Child the Client must complete the Enrollment Form (Exhibit 1), the Maternal Health History - Genetic Mother (Exhibit 3, as applicable), the Maternal health History - Non-Client Birth Mother (Exhibit 4, as applicable) and must read, understand, fill and sign all Exhibits (2, 5, 6, 7 and 8) and make due payment of fees.
3.2
Client is responsible for providing the Collection Kit to the Caregiver at the time of child birth, and for arranging with the Caregiver for collection, preparation and
President, LifeCell International
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.
Fees for Services.
4.1.
21-Year Storage Plan. Pursuant to the 21-year Storage Plan, Client makes a one- time payment which includes the processing and testing fee and storage of the Specimen for a period of 21-years.
4.2.
4.3.
Client may also to choose to subscribe for additional services such as newborn genetic testing and/or, expansion of Mesenchymal stem cells from umbilical cord tissue as listed in Exhibit 2 and pay the additional fees. All fees paid by Client to LifeCell are non-refundable. However in the event of the Specimen being unfit for processing, the processing and storage fees would be refunded, and in case the Specimen is found to be unfit for storage, the storage fees would be refunded.
5.
Terms of Agreement.
5.1.
This Agreement will continue for twenty one (21) years from the date of birth of the Child.
5.2.
LifeCell will make reasonable attempts to notify the Client or the Child about the scheduled expiry of this Agreement at least 60 days in advance before the Child completes the age of twenty one (21) years.
5.3.
If the Client or the Child consents his/her willingness to continue the storage beyond 21 years, the Child shall enter into a new Agreement with LifeCell as per the then prevailing terms and storage fee.
6.
Representations and Warranties of Client. 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 consult Client's own legal counsel to review this Agreement and related forms and Client has carefully read and understood all the terms of this Agreement;
6.3.
The decision to collect the Specimen and Maternal Blood,
Client's Initials
Husband's Initials
Birth Mother, if not Client
test the Maternal Blood and process and store the Specimen is a completely voluntary act of Client; 6.4.
Client has discussed with a competent medical professional, who is not an employee or agent of LifeCell, regarding the collection, processing, storage and possible future use of the Specimen, including possible risks as laid out in Exhibit 8.
7.
Obligations and Rights to Specimen.
7.1.
If only one parent/legal guardian of the Child is the Client, such person shall be solely liable for all of the obligations and shall have all rights of the Client, including control of the Specimen. If more than one parent/legal guardian of the Child is the Client each shall be jointly and severally liable and the rights shall be held by such parents/legal guardians jointly, including control of the Specimen. The exercise of any rights and control over the Specimen will require written notice to LifeCell signed by each Client.
7.2.
Any components (including but not limited to plasma and red blood cells) that remain after the Specimen is processed and that are not being stored, will be disposed off by LifeCell.
7.3.
In the event of disagreement between the parents, the Genetic Mother's wish and right shall prevail. On the Child attaining the age of majority, the rights and wishes of the Child shall prevail.
8.
Retrieval of Specimen.
8.1.
There is no fee payable by the Client to LifeCell for retrieval of Specimen.
8.2.
The stored Specimen will be available for access or delivery by or before the end of the 7th business day after LifeCell's receipt of a written request from Client. However if the Client’s chosen plan also covers isolation and expansion of stem cells at the time of retrieval, the expanded cells would be available for access or delivery by or before the end of 90th business day after LifeCell’s receipt of a written request from Client.
8.3.
The request must be made on a request form provided by LifeCell. This must be signed by the Client, and provide the name and address of the facility where the Specimen is to be delivered and the date of delivery is requested.
8.4.
If the retrieval is requested for a transplant, the request form must be accompanied by transplant physician’s certification confirming te end-use. The stored
President, LifeCell International
Specimen can only be released for use in compliance with the statutory regulations at the place of transplant. 8.5.
Free Worldwide Shipment: In the event of a transplant, the Specimen would be m a d e available for transportation in a special cryo-shipper owned by LifeCell. For purposes of convenience, LifeCell on the request of the Client shall make necessary arrangements with a certified Service Provider who has the required expertise in handling and transportation of such Specimen at no additional costs to the Client. The Service Provider is not an agent of LifeCell and LifeCell shall not be responsible in any manner for the services rendered by the Service Provider.
9.
LifeCell Client Benefit Programs: LifeCell understands the Clients need to enhance the Value of their investment and also provide a comprehensive coverage for their Child. Therefore LifeCell through its Client Benefit Programs provide additional guarantees, insurances, and benefits which are detailed below:
9.1.
LifeCell Cares Program: LifeCell understands that there may arise financial hardship in the event your Child's Specimen is required for a stem cell transplant in which case LifeCell under its LifeCell Cares Program will provide the Client upto US$ 10,000 (Ten Thousand US Dollars only) to offset treatment related and personal family expenses, provided the following conditions are satisfied:
9.1.1.
The Child or its Sibling must be positively diagnosed after the enrolment date for a hematological malignancy treatable using the stored Specimen.
9.1.2. The Specimen must be retrieved for a hematopoietic stem cell transplant, and must be administered under the direction of a transplant physician in a medical facility qualified and approved by a competent authority for stem cell transplantation. 9.2.
LifeCell Disaster Relief Program: While LifeCell shall ensure that the preserved Specimen will be maintained with utmost care, there may be unforeseen events that may occur, which are beyond the reasonable control of LifeCell and which may potentially deteriorate the Specimen during transit or whilst being held in cryo preservation facility. In the extremely unlikely occurrence of such event, LifeCell will use its best endeavors to find a unit of suitable
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 10 of 45
Page 11 of 45
2.3
LifeCell will provide the Client with the following immediately upon enrollment:
labeling of the Maternal Blood and the Specimen for delivery to LifeCell, in accordance to the instructions provided by LifeCell. The Client or the authorized representative of the Client shall also ensure that the forms included in the Collection Kit are duly filled up and sent to LifeCell.
2.3.1. A Collection Kit 2.3.2. A copy of this Agreement 2.3.3. A unique Client Relationship Management (CRM) identification number that enables the Client to quote for all communications with LifeCell. 2.4.
2.6.
2.7.
LifeCell at the request of the Client would arrange for pick-up of the Maternal Blood and Specimen from the Hospital / Birthing center to LifeCell Laboratory, using a certified Service Provider who has the required expertise in the correct handling and transportation of such Maternal Blood and Specimen at no additional costs to the Client. The Service Provider is not an agent of LifeCell and LifeCell shall not be responsible in any manner for the services rendered by the Service Provider. 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 including but not limited to cell counts, sterility, viability, and infectious disease screening for Syphilis, Malaria, Hepatitis B, Hepatitis C, Human Immunodeficiency Virus, and Cytomegalovirus. In the event that the Specimen is determined by LifeCell to be unfit for processing and / or storage for any reason, such as insuf ficient volume, low cell count / viability, positive screening of infectious diseases, microbial contamination of Specimen, etc., then LifeCell will notify the Client immediately, and seek instructions for disposal of the Specimen. If LifeCell does not receive written instructions within 60 days of such notice then LifeCell has the right to terminate the Agreement and destroy the Specimen without further liability.
3.
Client Responsibilities.
3.1.
Prior to the birth of the Child the Client must complete the Enrollment Form (Exhibit 1), the Maternal Health History - Genetic Mother (Exhibit 3, as applicable), the Maternal health History - Non-Client Birth Mother (Exhibit 4, as applicable) and must read, understand, fill and sign all Exhibits (2, 5, 6, 7 and 8) and make due payment of fees.
3.2
Client is responsible for providing the Collection Kit to the Caregiver at the time of child birth, and for arranging with the Caregiver for collection, preparation and
President, LifeCell International
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.
Fees for Services.
4.1.
21-Year Storage Plan. Pursuant to the 21-year Storage Plan, Client makes a one- time payment which includes the processing and testing fee and storage of the Specimen for a period of 21-years.
4.2.
4.3.
Client may also to choose to subscribe for additional services such as newborn genetic testing and/or, expansion of Mesenchymal stem cells from umbilical cord tissue as listed in Exhibit 2 and pay the additional fees. All fees paid by Client to LifeCell are non-refundable. However in the event of the Specimen being unfit for processing, the processing and storage fees would be refunded, and in case the Specimen is found to be unfit for storage, the storage fees would be refunded.
5.
Terms of Agreement.
5.1.
This Agreement will continue for twenty one (21) years from the date of birth of the Child.
5.2.
LifeCell will make reasonable attempts to notify the Client or the Child about the scheduled expiry of this Agreement at least 60 days in advance before the Child completes the age of twenty one (21) years.
5.3.
If the Client or the Child consents his/her willingness to continue the storage beyond 21 years, the Child shall enter into a new Agreement with LifeCell as per the then prevailing terms and storage fee.
6.
Representations and Warranties of Client. 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 consult Client's own legal counsel to review this Agreement and related forms and Client has carefully read and understood all the terms of this Agreement;
6.3.
The decision to collect the Specimen and Maternal Blood,
Client's Initials
Husband's Initials
Birth Mother, if not Client
test the Maternal Blood and process and store the Specimen is a completely voluntary act of Client; 6.4.
Client has discussed with a competent medical professional, who is not an employee or agent of LifeCell, regarding the collection, processing, storage and possible future use of the Specimen, including possible risks as laid out in Exhibit 8.
7.
Obligations and Rights to Specimen.
7.1.
If only one parent/legal guardian of the Child is the Client, such person shall be solely liable for all of the obligations and shall have all rights of the Client, including control of the Specimen. If more than one parent/legal guardian of the Child is the Client each shall be jointly and severally liable and the rights shall be held by such parents/legal guardians jointly, including control of the Specimen. The exercise of any rights and control over the Specimen will require written notice to LifeCell signed by each Client.
7.2.
Any components (including but not limited to plasma and red blood cells) that remain after the Specimen is processed and that are not being stored, will be disposed off by LifeCell.
7.3.
In the event of disagreement between the parents, the Genetic Mother's wish and right shall prevail. On the Child attaining the age of majority, the rights and wishes of the Child shall prevail.
8.
Retrieval of Specimen.
8.1.
There is no fee payable by the Client to LifeCell for retrieval of Specimen.
8.2.
The stored Specimen will be available for access or delivery by or before the end of the 7th business day after LifeCell's receipt of a written request from Client. However if the Client’s chosen plan also covers isolation and expansion of stem cells at the time of retrieval, the expanded cells would be available for access or delivery by or before the end of 90th business day after LifeCell’s receipt of a written request from Client.
8.3.
The request must be made on a request form provided by LifeCell. This must be signed by the Client, and provide the name and address of the facility where the Specimen is to be delivered and the date of delivery is requested.
8.4.
If the retrieval is requested for a transplant, the request form must be accompanied by transplant physician’s certification confirming te end-use. The stored
President, LifeCell International
Specimen can only be released for use in compliance with the statutory regulations at the place of transplant. 8.5.
Free Worldwide Shipment: In the event of a transplant, the Specimen would be m a d e available for transportation in a special cryo-shipper owned by LifeCell. For purposes of convenience, LifeCell on the request of the Client shall make necessary arrangements with a certified Service Provider who has the required expertise in handling and transportation of such Specimen at no additional costs to the Client. The Service Provider is not an agent of LifeCell and LifeCell shall not be responsible in any manner for the services rendered by the Service Provider.
9.
LifeCell Client Benefit Programs: LifeCell understands the Clients need to enhance the Value of their investment and also provide a comprehensive coverage for their Child. Therefore LifeCell through its Client Benefit Programs provide additional guarantees, insurances, and benefits which are detailed below:
9.1.
LifeCell Cares Program: LifeCell understands that there may arise financial hardship in the event your Child's Specimen is required for a stem cell transplant in which case LifeCell under its LifeCell Cares Program will provide the Client upto US$ 10,000 (Ten Thousand US Dollars only) to offset treatment related and personal family expenses, provided the following conditions are satisfied:
9.1.1.
The Child or its Sibling must be positively diagnosed after the enrolment date for a hematological malignancy treatable using the stored Specimen.
9.1.2. The Specimen must be retrieved for a hematopoietic stem cell transplant, and must be administered under the direction of a transplant physician in a medical facility qualified and approved by a competent authority for stem cell transplantation. 9.2.
LifeCell Disaster Relief Program: While LifeCell shall ensure that the preserved Specimen will be maintained with utmost care, there may be unforeseen events that may occur, which are beyond the reasonable control of LifeCell and which may potentially deteriorate the Specimen during transit or whilst being held in cryo preservation facility. In the extremely unlikely occurrence of such event, LifeCell will use its best endeavors to find a unit of suitable
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 10 of 45
Page 11 of 45
HLA match or pay up to US$ 25,000 (Twenty Five Thousand US Dollars only) subject to the following conditions:
11.
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. Such limitation of liability shall in no way be diminished as a result of the LifeCell Cares Program or in the event that liability arising from acts committed by LifeCell that are intentional and grossly negligent.
9.2.1. The Child or its Sibling must be positively diagnosed after the Enrolment date for a hematological malignancy treatable using the stored Specimen, and must be scheduled for a stem cell transplant. 9.2.2 The Specimen is lost due to change in temperature arising out of loss or damage to the cold storage machinery due to operation of an insured peril (i.e.) fire, lighting, explosion and implosion, aircraft damage, riot, strike, malicious damage and terrorism, storm, tempest and flood and inundation, impact damage, subsidence and landslide/rockslide, bursting and/or overflowing of water tanks, apparatus and pipes, missile testing, leakage from automatic sprinkler installation, bush fire, earthquake (fire and shock), and act of terrorism. 9.3
9.4.
12.
General Conditions for LifeCell Client Benefit Programs:
Force Majeure: Client agrees that lifecell shall not be liable for any loss, deterioration or destruction of all or any part of the specimen resulting from causes or circumstances which are beyond LifeCell’s reasonable control.
3.
Indemnity to Hold Harmless. Client agrees to indemnify and hold LifeCell, its respective agents, employees, officers, directors, shareholders and affiliates harmless from any and all claims, liabilities, demands and causes of action asserted against them by any third party.
LifeCell Payment Guarantee: If the Client's Specimen upon retrieval for a hematopoietic stem cell transplant does not meet LifeCell's then prevailing viability criteria benchmarked against existing international best practices then LifeCell will use its best endeavors to find a unit of suitable HLA match to the Child or pay the Client upto US$ 25,000 (Twenty Five Thousand US Dollars only).
Limitation of Liability:
14.
Termination of Agreement.
14.1
This Agreement may be terminated
14.1.1. by Client at any time prior to the collection of the Specimen, or
9.4.2. Payments would be made on appropriate verification of Client’s request by LifeCell.
14.1.2. by LifeCell if it has exercised its right to refuse Specimen storage for any reason, including the consequential act of Sample rejection as per clause 2.7, or
9.4.3. Upon payment (or providing a unit of suitable HLA match) Client would thereby discharge and release LifeCell from all its liabilities.
14.1.3. 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, or
10.
Disclaimers.
14.1.4. by mutual agreement of Client and LifeCell, or
Neither LifeCell nor any of its officers, directors, shareholders, employees, agents or consultants have made any representations, guarantee, warranties or assurances, express or implied, to Client of any kind o t h e r than those disclosed herein LifeCell does not perform any medical services, give any medical advice, or otherwise perform any functions other t h a n t hose expr essl y indicat ed; Lif eCell expr essl y disclaims any responsibility to provide any other. services.
14.1.5. by either party upon 60 days prior written notice to the other party hereto, or
9.4.1. The Client Agreement is valid and is in force.
President, LifeCell International
14.1.6. in the event, the Specimen are retrieved for a transplant. However, if the Client retrieves only a portion of the Specimen the Agreement would survive and continue until the entire Specimen has been retrieved. 14.2
Effects of Termination:
Client's Initials
Husband's Initials
Birth Mother, if not Client
14.2.1. If the Agreement is terminated under Section 14.1.3, 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. 14.2.2. If the Agreement is terminated by LifeCell under Section 14.1.5, 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. 14.2.3. If the Agreement is terminated under Section 14.1.6 a pro-rated refund of the prepaid store fees will be made by LifeCell to the Client 15.
Arbitration. All disputes arising out of or relating to this Agreement will be resolved by arbitration. The arbitration will take place in Dubai, UAE as per the applicable laws of UAE. All decisions of the arbitrator shall be final, binding, and conclusive and arbitration constitutes the only method of resolving disputes to this Agreement.
16.
17.
18.
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. 19.
20.
Notice.
20.1.
Any notice shall be sufficiently given if delivered in person or sent by express mail or by registered or certified mail, postage prepaid.
20.2. Notice to LifeCell must be delivered to LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, Dubai Media City, P.O. Box. 502026, Dubai, United Arab Emirates. 20.3. Notice to Client will be delivered to the address set forth in the Enrollment form or as updated by client to LifeCell. 21.
Entire Agreement. This Agreement and the exhibits hereto constitute the entire agreement between LifeCell, Client and, if different, the birth mother of the Child and supersedes any prior agreements or understandings, oral and written.
This Agreement is governed by, construed and interpreted in accordance with the local laws of Dubai, UAE. Any Judicial proceedings brought against either LifeCell or Client under this agreement will be brought in a competent court in Dubai, UAE. LifeCell and Client consent to the exclusive jurisdiction of the aforesaid courts and waive any objection to venue therein and irrevocably agree to be bound by any judgement rendered thereby in connection with this Agreement.
22.
Confidentiality; Consent to Release.
23.
President, LifeCell International
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.
Governing Law and Jurisdiction.
LifeCell acknowledges the confidential nature of the information provided by Client and, if different from the Client, the Birth Mother of the Child and agrees to use its reasonable best efforts to maintain the confidentiality of the information except as required by law or as permitted by this Agreement. Client and, if different, the Birth Mother of the Child hereby agree to the release of information to the hospital, laboratory or physician providing the services to the Client.
Multiple Births.
Survival. All pr ovisions which by t heir t er ms r equir e performance after the termination of this Agreement will survive the termination of this Agreement. Binding Effect. All of the obligations, terms, provisions and releases set forth in this Agreement, shall be binding upon and inure to the benefit of LifeCell, the Client and their respective heirs, personal representatives, successors and assigns.
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 12 of 45
Page 13 of 45
HLA match or pay up to US$ 25,000 (Twenty Five Thousand US Dollars only) subject to the following conditions:
11.
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. Such limitation of liability shall in no way be diminished as a result of the LifeCell Cares Program or in the event that liability arising from acts committed by LifeCell that are intentional and grossly negligent.
9.2.1. The Child or its Sibling must be positively diagnosed after the Enrolment date for a hematological malignancy treatable using the stored Specimen, and must be scheduled for a stem cell transplant. 9.2.2 The Specimen is lost due to change in temperature arising out of loss or damage to the cold storage machinery due to operation of an insured peril (i.e.) fire, lighting, explosion and implosion, aircraft damage, riot, strike, malicious damage and terrorism, storm, tempest and flood and inundation, impact damage, subsidence and landslide/rockslide, bursting and/or overflowing of water tanks, apparatus and pipes, missile testing, leakage from automatic sprinkler installation, bush fire, earthquake (fire and shock), and act of terrorism. 9.3
9.4.
12.
General Conditions for LifeCell Client Benefit Programs:
Force Majeure: Client agrees that lifecell shall not be liable for any loss, deterioration or destruction of all or any part of the specimen resulting from causes or circumstances which are beyond LifeCell’s reasonable control.
3.
Indemnity to Hold Harmless. Client agrees to indemnify and hold LifeCell, its respective agents, employees, officers, directors, shareholders and affiliates harmless from any and all claims, liabilities, demands and causes of action asserted against them by any third party.
LifeCell Payment Guarantee: If the Client's Specimen upon retrieval for a hematopoietic stem cell transplant does not meet LifeCell's then prevailing viability criteria benchmarked against existing international best practices then LifeCell will use its best endeavors to find a unit of suitable HLA match to the Child or pay the Client upto US$ 25,000 (Twenty Five Thousand US Dollars only).
Limitation of Liability:
14.
Termination of Agreement.
14.1
This Agreement may be terminated
14.1.1. by Client at any time prior to the collection of the Specimen, or
9.4.2. Payments would be made on appropriate verification of Client’s request by LifeCell.
14.1.2. by LifeCell if it has exercised its right to refuse Specimen storage for any reason, including the consequential act of Sample rejection as per clause 2.7, or
9.4.3. Upon payment (or providing a unit of suitable HLA match) Client would thereby discharge and release LifeCell from all its liabilities.
14.1.3. 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, or
10.
Disclaimers.
14.1.4. by mutual agreement of Client and LifeCell, or
Neither LifeCell nor any of its officers, directors, shareholders, employees, agents or consultants have made any representations, guarantee, warranties or assurances, express or implied, to Client of any kind o t h e r than those disclosed herein LifeCell does not perform any medical services, give any medical advice, or otherwise perform any functions other t h a n t hose expr essl y indicat ed; Lif eCell expr essl y disclaims any responsibility to provide any other. services.
14.1.5. by either party upon 60 days prior written notice to the other party hereto, or
9.4.1. The Client Agreement is valid and is in force.
President, LifeCell International
14.1.6. in the event, the Specimen are retrieved for a transplant. However, if the Client retrieves only a portion of the Specimen the Agreement would survive and continue until the entire Specimen has been retrieved. 14.2
Effects of Termination:
Client's Initials
Husband's Initials
Birth Mother, if not Client
14.2.1. If the Agreement is terminated under Section 14.1.3, 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. 14.2.2. If the Agreement is terminated by LifeCell under Section 14.1.5, 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. 14.2.3. If the Agreement is terminated under Section 14.1.6 a pro-rated refund of the prepaid store fees will be made by LifeCell to the Client 15.
Arbitration. All disputes arising out of or relating to this Agreement will be resolved by arbitration. The arbitration will take place in Dubai, UAE as per the applicable laws of UAE. All decisions of the arbitrator shall be final, binding, and conclusive and arbitration constitutes the only method of resolving disputes to this Agreement.
16.
17.
18.
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. 19.
20.
Notice.
20.1.
Any notice shall be sufficiently given if delivered in person or sent by express mail or by registered or certified mail, postage prepaid.
20.2. Notice to LifeCell must be delivered to LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, Dubai Media City, P.O. Box. 502026, Dubai, United Arab Emirates. 20.3. Notice to Client will be delivered to the address set forth in the Enrollment form or as updated by client to LifeCell. 21.
Entire Agreement. This Agreement and the exhibits hereto constitute the entire agreement between LifeCell, Client and, if different, the birth mother of the Child and supersedes any prior agreements or understandings, oral and written.
This Agreement is governed by, construed and interpreted in accordance with the local laws of Dubai, UAE. Any Judicial proceedings brought against either LifeCell or Client under this agreement will be brought in a competent court in Dubai, UAE. LifeCell and Client consent to the exclusive jurisdiction of the aforesaid courts and waive any objection to venue therein and irrevocably agree to be bound by any judgement rendered thereby in connection with this Agreement.
22.
Confidentiality; Consent to Release.
23.
President, LifeCell International
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.
Governing Law and Jurisdiction.
LifeCell acknowledges the confidential nature of the information provided by Client and, if different from the Client, the Birth Mother of the Child and agrees to use its reasonable best efforts to maintain the confidentiality of the information except as required by law or as permitted by this Agreement. Client and, if different, the Birth Mother of the Child hereby agree to the release of information to the hospital, laboratory or physician providing the services to the Client.
Multiple Births.
Survival. All pr ovisions which by t heir t er ms r equir e performance after the termination of this Agreement will survive the termination of this Agreement. Binding Effect. All of the obligations, terms, provisions and releases set forth in this Agreement, shall be binding upon and inure to the benefit of LifeCell, the Client and their respective heirs, personal representatives, successors and assigns.
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 12 of 45
Page 13 of 45
24.
Severability.
25.
If any part of this Agreement is found to be invalid or unenforceable, such provision is deemed modified to the extent nece sary to make the Agreement enforceable, and this Agreement shall otherwise remain in full force and effect.
Headings.
UMBILICAL CORD STEM CELL TESTING, PROCESSING, STORAGE AND INFORMED CONSENT AGREEMENT
The headings in this Agreement are for reference purposes only and shall not affect the meaning or interpretation of this Agreement.
I/We, the undersigned (the ‘Client’), on behalf of myself/ourselves and my/our unborn child (the ‘Child’), engage LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, Dubai Media City, PO Box 502026, Dubai, UAE (‘LifeCell’), 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 on the following terms (this ‘Agreement’).
I ACCEPT ALL TERMS AND CONDITIONS OF THIS AGREEMENT
This Agreement is entered into this _________ day of ___________________, 201______ (the ‘Enrollment Date’) and legally Name and Signature of Mother/Legal Guardian
Name and Signature of Father/Legal Guardian
Name of Birth Mother if not the Client
Signature of Birth Mother if not the Client
binds LifeCell and the Client, including the birth mother of the Child.
1. Definitions: In this Agreement, (including the recitals above), unless the context otherwise requires, the following expressions shall have the following meanings:
Date:
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.
‘Birth Mother’ means the one who has borne the child in her womb.
1.4.
‘Genetic Mother’ if different from the Birth Mother means the mother from whom the egg has been obtained.
1.5.
‘Caregiver’ means the Obstetrician / Gynecologist or qualified medical professional / midwife who will be assisting in delivering the Child.
1.6.
1.7.
1.8.
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
packed in a certified transport container compliant with International Air Transport Association (IATA) regulations. 1.9.
‘LifeCell Laboratory’ means LifeCell's licensed and accredited laboratory facilities where the Specimen is processed, tested, and/or stored at Cryo-Cell laboratory, USA at the option of the Client as per the chosen plan.
1.10.
‘Minimally Manipulated Stem Cells’ means stem cells that have not been subjected to ex- vivo procedure such as expansion of cell populations, genetic alterations, etc.
1.11.
‘Minimally Expanded Stem Cells’ means cells that have been obtained from ex-vivo isolation and not subjected to further passaging.
1.12.
‘Hematopoietic Stem Cells’ means multipotent stem cells that are characterized by the expression of the marker CD34.
1.13.
‘Mesenchymal Stem Cells’ means multipotent stem cells that can differentiate into a variety of cell types and are characterized by expression of the markers CD90 and CD105.
1.14.
‘Sibling’ means a brother or sister of the Child having one or both parents in common.
2.
Services of LifeCell; Testing, Processing, Preserving and Storage.
2.1.
LifeCell offers its services under various options which the Client must choose from as detailed in Exhibit 2,
2.2.
LifeCell shall obtain all statutory permissions and licenses that might be required for providing the services contemplated under this Agreement.
Y
P O C NT
CLIE
‘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. ‘Specimen’ means and includes stem cells obtained from umbilical cord blood and /or umbilical cord tissue individually or collectively. ‘Collection Kit’ means the kit consisting all essential materials required for the purpose of collection and labeling of the Maternal Blood and Specimen, such as Cord Blood Collection Bag, Cord Tissue Collection Containers, Barcode labels, Vacuum Test Tubes, Foam Bricks, Alcohol Swabs, Hologram Stickers, Maternal Blood and Specimen Collection and Packing Instructions, Sealable Plastic Bags and Absorbent Paper Towels, and all
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 14 of 45
Page 15 of 45
24.
Severability.
25.
If any part of this Agreement is found to be invalid or unenforceable, such provision is deemed modified to the extent nece sary to make the Agreement enforceable, and this Agreement shall otherwise remain in full force and effect.
Headings.
UMBILICAL CORD STEM CELL TESTING, PROCESSING, STORAGE AND INFORMED CONSENT AGREEMENT
The headings in this Agreement are for reference purposes only and shall not affect the meaning or interpretation of this Agreement.
I/We, the undersigned (the ‘Client’), on behalf of myself/ourselves and my/our unborn child (the ‘Child’), engage LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, Dubai Media City, PO Box 502026, Dubai, UAE (‘LifeCell’), 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 on the following terms (this ‘Agreement’).
I ACCEPT ALL TERMS AND CONDITIONS OF THIS AGREEMENT
This Agreement is entered into this _________ day of ___________________, 201______ (the ‘Enrollment Date’) and legally Name and Signature of Mother/Legal Guardian
Name and Signature of Father/Legal Guardian
Name of Birth Mother if not the Client
Signature of Birth Mother if not the Client
binds LifeCell and the Client, including the birth mother of the Child.
1. Definitions: In this Agreement, (including the recitals above), unless the context otherwise requires, the following expressions shall have the following meanings:
Date:
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.
‘Birth Mother’ means the one who has borne the child in her womb.
1.4.
‘Genetic Mother’ if different from the Birth Mother means the mother from whom the egg has been obtained.
1.5.
‘Caregiver’ means the Obstetrician / Gynecologist or qualified medical professional / midwife who will be assisting in delivering the Child.
1.6.
1.7.
1.8.
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
packed in a certified transport container compliant with International Air Transport Association (IATA) regulations. 1.9.
‘LifeCell Laboratory’ means LifeCell's licensed and accredited laboratory facilities where the Specimen is processed, tested, and/or stored at Cryo-Cell laboratory, USA at the option of the Client as per the chosen plan.
1.10.
‘Minimally Manipulated Stem Cells’ means stem cells that have not been subjected to ex- vivo procedure such as expansion of cell populations, genetic alterations, etc.
1.11.
‘Minimally Expanded Stem Cells’ means cells that have been obtained from ex-vivo isolation and not subjected to further passaging.
1.12.
‘Hematopoietic Stem Cells’ means multipotent stem cells that are characterized by the expression of the marker CD34.
1.13.
‘Mesenchymal Stem Cells’ means multipotent stem cells that can differentiate into a variety of cell types and are characterized by expression of the markers CD90 and CD105.
1.14.
‘Sibling’ means a brother or sister of the Child having one or both parents in common.
2.
Services of LifeCell; Testing, Processing, Preserving and Storage.
2.1.
LifeCell offers its services under various options which the Client must choose from as detailed in Exhibit 2,
2.2.
LifeCell shall obtain all statutory permissions and licenses that might be required for providing the services contemplated under this Agreement.
Y
P O C NT
CLIE
‘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. ‘Specimen’ means and includes stem cells obtained from umbilical cord blood and /or umbilical cord tissue individually or collectively. ‘Collection Kit’ means the kit consisting all essential materials required for the purpose of collection and labeling of the Maternal Blood and Specimen, such as Cord Blood Collection Bag, Cord Tissue Collection Containers, Barcode labels, Vacuum Test Tubes, Foam Bricks, Alcohol Swabs, Hologram Stickers, Maternal Blood and Specimen Collection and Packing Instructions, Sealable Plastic Bags and Absorbent Paper Towels, and all
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 14 of 45
Page 15 of 45
2.3
LifeCell will provide the Client with the following immediately upon enrollment:
labeling of the Maternal Blood and the Specimen for delivery to LifeCell, in accordance to the instructions provided by LifeCell. The Client or the authorized representative of the Client shall also ensure that the forms included in the Collection Kit are duly filled up and sent to LifeCell.
2.3.1. A Collection Kit 2.3.2. A copy of this Agreement 2.3.3. A unique Client Relationship Management (CRM) identification number that enables the Client to quote for all communications with LifeCell. 2.4.
2.6.
2.7.
LifeCell at the request of the Client would arrange for pick-up of the Maternal Blood and Specimen from the Hospital / Birthing center to LifeCell Laboratory, using a certified Service Provider who has the required expertise in the correct handling and transportation of such Maternal Blood and Specimen at no additional costs to the Client. The Service Provider is not an agent of LifeCell and LifeCell shall not be responsible in any manner for the services rendered by the Service Provider. Upon successful collection, processing and storage, LifeCell will provide the Client w i t h a P r e s e r v a t i o n Certificate confirming successful storage of the Specimen along with sample storage details and test results including but not limited to cell counts, sterility, viability, and infectious disease screening for Syphilis, Malaria, Hepatitis B, Hepatitis C, Human Immunodeficiency Virus, and Cytomegalovirus.
Client Responsibilities.
3.1.
Prior to the birth of the Child the Client must complete the Enrollment Form (Exhibit 1), the Maternal Health History - Genetic Mother (Exhibit 3, as applicable),the Maternal health History - Non-Client Birth Mother (Exhibit 4, as applicable) and must read, understand, fill and sign all Exhibits (2, 5, 6, 7 and 8) and make due payment of fees. Client is responsible for providing the Collection Kit to the Caregiver at the time of child birth, and for arranging with the Caregiver for collection, preparation and
President, LifeCell International
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.
Fees for Services.
4.1.
21-Year Storage Plan. Pursuant to the 21-year Storage Plan, Client makes a one- time payment which includes the processing and testing fee and storage of the Specimen for a period of 21-years.
4.2.
4.3.
Client may also to choose to subscribe for additional services such as newborn genetic testing and/or, expansion of Mesenchymal stem cells from umbilical cord tissue as listed in Exhibit 2 and pay the additional fees. All fees paid by Client to LifeCell are non-refundable. However in the event of the Specimen being unfit for processing, the processing and storage fees would be refunded, and in case the Specimen is found to be unfit for storage, the storage fees would be refunded.
PY O C T
N
CLIE
In the event that the Specimen is determined by LifeCell to be unfit for processing and / or storage for any reason, such as insuf ficient volume, low cell count / viability, positive screening of infectious diseases, microbial contamination of Specimen, etc., then LifeCell will notify the Client immediately, and seek instructions for disposal of the Specimen. If LifeCell does not receive written instructions within 60 days of such notice then LifeCell has the right to terminate the Agreement and destroy the Specimen without further liability.
3.
3.2
3.3.
5.
Terms of Agreement.
5.1.
This Agreement will continue for twenty one (21) years from the date of birth of the Child.
5.2.
LifeCell will make reasonable attempts to notify the Client or the Child about the scheduled expiry of this Agreement at least 60 days in advance before the Child completes the age of twenty one (21) years.
5.3.
If the Client or the Child consents his/her willingness to continue the storage beyond 21 years, the Child shall enter into a new Agreement with LifeCell as per the then prevailing terms and storage fee.
6.
Representations and Warranties of Client. 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 consult Client's own legal counsel to review this Agreement and related forms and Client has carefully read and understood all the terms of this Agreement;
6.3.
The decision to collect the Specimen and Maternal Blood,
Client's Initials
Husband's Initials
Birth Mother, if not Client
test the Maternal Blood and process and store the Specimen is a completely voluntary act of Client; 6.4.
Client has discussed with a competent medical professional, who is not an employee or agent of LifeCell, regarding the collection, processing, storage and possible future use of the Specimen, including possible risks as laid out in Exhibit 8.
7.
Obligations and Rights to Specimen.
7.1.
If only one parent/legal guardian of the Child is the Client, such person shall be solely liable for all of the obligations and shall have all rights of the Client, including control of the Specimen. If more than one parent/legal guardian of the Child is the Client each shall be jointly and severally liable and the rights shall be held by such parents/legal guardians jointly, including control of the Specimen. The exercise of any rights and control over the Specimen will require written notice to LifeCell signed by each Client.
7.2.
7.3.
Specimen can only be released for use in compliance with the statutory regulations at the place of transplant. 8.5.
In the event of a transplant, the Specimen would be m a d e available for transportation in a special cryo-shipper owned by LifeCell. For purposes of convenience, LifeCell on the request of the Client shall make necessary arrangements with a certified Service Provider who has the required expertise in handling and transportation of such Specimen at no additional costs to the Client. The Service Provider is not an agent of LifeCell and LifeCell shall not be responsible in any manner for the services rendered by the Service Provider. 9.
9.1.
8.
Retrieval of Specimen.
8.1.
There is no fee payable by the Client to LifeCell for retrieval of Specimen.
8.2.
The stored Specimen will be available for access or delivery by or before the end of the 7th business day after LifeCell's receipt of a written request from Client. However if the Client’s chosen plan also covers isolation and expansion of stem cells at the time of retrieval, the expanded cells would be available for access or delivery by or before the end of 90th business day after LifeCell’s receipt of a written request from Client.
8.3.
The request must be made on a request form provided by LifeCell. This must be signed by the Client, and provide the name and address of the facility where the Specimen is to be delivered and the date of delivery is requested.
8.4.
If the retrieval is requested for a transplant, the request form must be accompanied by transplant physician’s certification confirming te end-use. The stored
President, LifeCell International
LifeCell Cares Program:
PY O C T
LifeCell understands that there may arise financial hardship in the event your Child's Specimen is required for a stem cell transplant in which case LifeCell under its LifeCell Cares Program will provide the Client upto US$ 10,000 (Ten Thousand US Dollars only) to offset treatment related and personal family expenses, provided the following conditions are satisfied:
N
CLIE
LifeCell Client Benefit Programs: LifeCell understands the Clients need to enhance the Value of their investment and also provide a comprehensive coverage for their Child. Therefore LifeCell through its Client Benefit Programs provide additional guarantees, insurances, and benefits which are detailed below:
Any components (including but not limited to plasma and red blood cells) that remain after the Specimen is processed and that are not being stored, will be disposed off by LifeCell. In the event of disagreement between the parents, the Genetic Mother's wish and right shall prevail. On the Child attaining the age of majority, the rights and wishes of the Child shall prevail.
Free Worldwide Shipment:
9.1.1.
The Child or its Sibling must be positively diagnosed after the enrolment date for a hematological malignancy treatable using the stored Specimen.
9.1.2. The Specimen must be retrieved for a hematopoietic stem cell transplant, and must be administered under the direction of a transplant physician in a medical facility qualified and approved by a competent authority for stem cell transplantation. 9.2.
LifeCell Disaster Relief Program: While LifeCell shall ensure that the preserved Specimen will be maintained with utmost care, there may be unforeseen events that may occur, which are beyond the reasonable control of LifeCell and which may potentially deteriorate the Specimen during transit or whilst being held in cryo preservation facility. In the extremely unlikely occurrence of such event, LifeCell will use its best endeavors to find a unit of suitable
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 16 of 45
Page 117 of 45
2.3
LifeCell will provide the Client with the following immediately upon enrollment:
labeling of the Maternal Blood and the Specimen for delivery to LifeCell, in accordance to the instructions provided by LifeCell. The Client or the authorized representative of the Client shall also ensure that the forms included in the Collection Kit are duly filled up and sent to LifeCell.
2.3.1. A Collection Kit 2.3.2. A copy of this Agreement 2.3.3. A unique Client Relationship Management (CRM) identification number that enables the Client to quote for all communications with LifeCell. 2.4.
2.6.
2.7.
LifeCell at the request of the Client would arrange for pick-up of the Maternal Blood and Specimen from the Hospital / Birthing center to LifeCell Laboratory, using a certified Service Provider who has the required expertise in the correct handling and transportation of such Maternal Blood and Specimen at no additional costs to the Client. The Service Provider is not an agent of LifeCell and LifeCell shall not be responsible in any manner for the services rendered by the Service Provider. Upon successful collection, processing and storage, LifeCell will provide the Client w i t h a P r e s e r v a t i o n Certificate confirming successful storage of the Specimen along with sample storage details and test results including but not limited to cell counts, sterility, viability, and infectious disease screening for Syphilis, Malaria, Hepatitis B, Hepatitis C, Human Immunodeficiency Virus, and Cytomegalovirus.
Client Responsibilities.
3.1.
Prior to the birth of the Child the Client must complete the Enrollment Form (Exhibit 1), the Maternal Health History - Genetic Mother (Exhibit 3, as applicable),the Maternal health History - Non-Client Birth Mother (Exhibit 4, as applicable) and must read, understand, fill and sign all Exhibits (2, 5, 6, 7 and 8) and make due payment of fees. Client is responsible for providing the Collection Kit to the Caregiver at the time of child birth, and for arranging with the Caregiver for collection, preparation and
President, LifeCell International
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.
Fees for Services.
4.1.
21-Year Storage Plan. Pursuant to the 21-year Storage Plan, Client makes a one- time payment which includes the processing and testing fee and storage of the Specimen for a period of 21-years.
4.2.
4.3.
Client may also to choose to subscribe for additional services such as newborn genetic testing and/or, expansion of Mesenchymal stem cells from umbilical cord tissue as listed in Exhibit 2 and pay the additional fees. All fees paid by Client to LifeCell are non-refundable. However in the event of the Specimen being unfit for processing, the processing and storage fees would be refunded, and in case the Specimen is found to be unfit for storage, the storage fees would be refunded.
PY O C T
N
CLIE
In the event that the Specimen is determined by LifeCell to be unfit for processing and / or storage for any reason, such as insuf ficient volume, low cell count / viability, positive screening of infectious diseases, microbial contamination of Specimen, etc., then LifeCell will notify the Client immediately, and seek instructions for disposal of the Specimen. If LifeCell does not receive written instructions within 60 days of such notice then LifeCell has the right to terminate the Agreement and destroy the Specimen without further liability.
3.
3.2
3.3.
5.
Terms of Agreement.
5.1.
This Agreement will continue for twenty one (21) years from the date of birth of the Child.
5.2.
LifeCell will make reasonable attempts to notify the Client or the Child about the scheduled expiry of this Agreement at least 60 days in advance before the Child completes the age of twenty one (21) years.
5.3.
If the Client or the Child consents his/her willingness to continue the storage beyond 21 years, the Child shall enter into a new Agreement with LifeCell as per the then prevailing terms and storage fee.
6.
Representations and Warranties of Client. 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 consult Client's own legal counsel to review this Agreement and related forms and Client has carefully read and understood all the terms of this Agreement;
6.3.
The decision to collect the Specimen and Maternal Blood,
Client's Initials
Husband's Initials
Birth Mother, if not Client
test the Maternal Blood and process and store the Specimen is a completely voluntary act of Client; 6.4.
Client has discussed with a competent medical professional, who is not an employee or agent of LifeCell, regarding the collection, processing, storage and possible future use of the Specimen, including possible risks as laid out in Exhibit 8.
7.
Obligations and Rights to Specimen.
7.1.
If only one parent/legal guardian of the Child is the Client, such person shall be solely liable for all of the obligations and shall have all rights of the Client, including control of the Specimen. If more than one parent/legal guardian of the Child is the Client each shall be jointly and severally liable and the rights shall be held by such parents/legal guardians jointly, including control of the Specimen. The exercise of any rights and control over the Specimen will require written notice to LifeCell signed by each Client.
7.2.
7.3.
Specimen can only be released for use in compliance with the statutory regulations at the place of transplant. 8.5.
In the event of a transplant, the Specimen would be m a d e available for transportation in a special cryo-shipper owned by LifeCell. For purposes of convenience, LifeCell on the request of the Client shall make necessary arrangements with a certified Service Provider who has the required expertise in handling and transportation of such Specimen at no additional costs to the Client. The Service Provider is not an agent of LifeCell and LifeCell shall not be responsible in any manner for the services rendered by the Service Provider. 9.
9.1.
8.
Retrieval of Specimen.
8.1.
There is no fee payable by the Client to LifeCell for retrieval of Specimen.
8.2.
The stored Specimen will be available for access or delivery by or before the end of the 7th business day after LifeCell's receipt of a written request from Client. However if the Client’s chosen plan also covers isolation and expansion of stem cells at the time of retrieval, the expanded cells would be available for access or delivery by or before the end of 90th business day after LifeCell’s receipt of a written request from Client.
8.3.
The request must be made on a request form provided by LifeCell. This must be signed by the Client, and provide the name and address of the facility where the Specimen is to be delivered and the date of delivery is requested.
8.4.
If the retrieval is requested for a transplant, the request form must be accompanied by transplant physician’s certification confirming te end-use. The stored
President, LifeCell International
LifeCell Cares Program:
PY O C T
LifeCell understands that there may arise financial hardship in the event your Child's Specimen is required for a stem cell transplant in which case LifeCell under its LifeCell Cares Program will provide the Client upto US$ 10,000 (Ten Thousand US Dollars only) to offset treatment related and personal family expenses, provided the following conditions are satisfied:
N
CLIE
LifeCell Client Benefit Programs: LifeCell understands the Clients need to enhance the Value of their investment and also provide a comprehensive coverage for their Child. Therefore LifeCell through its Client Benefit Programs provide additional guarantees, insurances, and benefits which are detailed below:
Any components (including but not limited to plasma and red blood cells) that remain after the Specimen is processed and that are not being stored, will be disposed off by LifeCell. In the event of disagreement between the parents, the Genetic Mother's wish and right shall prevail. On the Child attaining the age of majority, the rights and wishes of the Child shall prevail.
Free Worldwide Shipment:
9.1.1.
The Child or its Sibling must be positively diagnosed after the enrolment date for a hematological malignancy treatable using the stored Specimen.
9.1.2. The Specimen must be retrieved for a hematopoietic stem cell transplant, and must be administered under the direction of a transplant physician in a medical facility qualified and approved by a competent authority for stem cell transplantation. 9.2.
LifeCell Disaster Relief Program: While LifeCell shall ensure that the preserved Specimen will be maintained with utmost care, there may be unforeseen events that may occur, which are beyond the reasonable control of LifeCell and which may potentially deteriorate the Specimen during transit or whilst being held in cryo preservation facility. In the extremely unlikely occurrence of such event, LifeCell will use its best endeavors to find a unit of suitable
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 16 of 45
Page 117 of 45
HLA match or pay up to US$ 25,000 (Twenty Five Thousand US Dollars only) subject to the following conditions:
11.
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. Such limitation of liability shall in no way be diminished as a result of the LifeCell Cares Program or in the event that liability arising from acts committed by LifeCell that are intentional and grossly negligent.
9.2.1. The Child or its Sibling must be positively diagnosed after the Enrolment date for a hematological malignancy treatable using the stored Specimen, and must be scheduled for a stem cell transplant. 9.2.2 The Specimen is lost due to change in temperature arising out of loss or damage to the cold storage machinery due to operation of an insured peril (i.e.) fire, lighting, explosion and implosion, aircraft damage, riot, strike, malicious damage and terrorism, storm, tempest and flood and inundation, impact damage, subsidence and landslide/rockslide, bursting and/or overflowing of water tanks, apparatus and pipes, missile testing, leakage from automatic sprinkler installation, bush fire, earthquake (fire and shock), and act of terrorism. 9.3
12.
Force Majeure: Client agrees that lifecell shall not be liable for any loss, deterioration or destruction of all or any part of the specimen resulting from causes or circumstances which are beyond LifeCell’s reasonable control.
3.
Indemnity to Hold Harmless. Client agrees to indemnify and hold LifeCell, its respective agents, employees, officers, directors, shareholders and affiliates harmless from any and all claims, liabilities, demands and causes of action asserted against them by any third party.
LifeCell Payment Guarantee: If the Client's Specimen upon retrieval for a hematopoietic stem cell transplant does not meet LifeCell's then prevailing viability criteria benchmarked against existing international best practices then LifeCell will use its best endeavors to find a unit of suitable HLA match to the Child or pay the Client upto US$ 25,000 (Twenty Five Thousand US Dollars only).
Limitation of Liability:
9.4.
General Conditions for LifeCell Client Benefit Programs:
14.
Termination of Agreement.
14.1
This Agreement may be terminated
14.1.1. by Client at any time prior to the collection of the Specimen, or
9.4.2. Payments would be made on appropriate verification of Client’s request by LifeCell.
14.1.2. by LifeCell if it has exercised its right to refuse Specimen storage for any reason, including the consequential act of Sample rejection as per clause 2.7, or
9.4.3. Upon payment (or providing a unit of suitable HLA match) Client would thereby discharge and release LifeCell from all its liabilities.
14.1.3. 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, or
10.
14.1.4. by mutual agreement of Client and LifeCell, or
9.4.1. The Client Agreement is valid and is in force.
Disclaimers. Neither LifeCell nor any of its officers, directors, shareholders, employees, agents or consultants have made any representations, guarantee, warranties or assurances, express or implied, to Client of any kind o t h e r than those disclosed herein LifeCell does not perform any medical services, give any medical advice, or otherwise perform any functions other t h a n t hose expr essl y indicat ed; Lif eCell expr essl y disclaims any responsibility to provide any other. services.
President, LifeCell International
14.1.5. by either party upon 60 days prior written notice to the other party hereto, or 14.1.6. in the event, the Specimen are retrieved for a transplant. However, if the Client retrieves only a portion of the Specimen the Agreement would survive and continue until the entire Specimen has been retrieved. 14.2
14.2.2. If the Agreement is terminated by LifeCell under Section 14.1.5, 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.
Effects of Termination:
Client's Initials
Husband's Initials
Birth Mother, if not Client
18.
Multiple Births.
19.
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. 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.
20.
Notice.
14.2.3. If the Agreement is terminated under Section 14.1.6 a pro-rated refund of the prepaid store fees will be made by LifeCell to the Client
20.1.
Any notice shall be sufficiently given if delivered in person or sent by express mail or by registered or certified mail, postage prepaid.
15.
20.2. Notice to LifeCell must be delivered to LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, Dubai Media City, P.O. Box. 502026, Dubai, United Arab Emirates.
Arbitration. All disputes arising out of or relating to this Agreement will be resolved by arbitration. The arbitration will take place in Dubai, UAE as per the applicable laws of UAE. All decisions of the arbitrator shall be final, binding, and conclusive and arbitration constitutes the only method of resolving disputes to this Agreement.
Y
P O C NT
CLIE
14.2.1. If the Agreement is terminated under Section 14.1.3, 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.
16.
Governing Law and Jurisdiction.
21.
CLIE
Confidentiality; Consent to Release. LifeCell acknowledges the confidential nature of the information provided by Client and, if different from the Client, the Birth Mother of the Child and agrees to use its reasonable best efforts to maintain the confidentiality of the information except as required by law or as permitted by this Agreement. Client and, if different, the Birth Mother of the Child hereby agree to the release of information to the hospital, laboratory or physician providing the services to the Client.
President, LifeCell International
Y
P O C NT
This Agreement is governed by, construed and interpreted in accordance with the local laws of Dubai, UAE. Any Judicial proceedings brought against either LifeCell or Client under this agreement will be brought in a competent court in Dubai, UAE. LifeCell and Client consent to the exclusive jurisdiction of the aforesaid courts and waive any objection to venue therein and irrevocably agree to be bound by any judgement rendered thereby in connection with this Agreement. 17.
20.3. Notice to Client will be delivered to the address set forth in the Enrollment form or as updated by client to LifeCell. Entire Agreement.
This Agreement and the exhibits hereto constitute the entire agreement between LifeCell, Client and, if different, the birth mother of the Child and supersedes any prior agreements or understandings, oral and written.
22.
Survival. All provisions which by their terms require performance after the termination of this Agreement will survive the termination of this Agreement.
23.
Binding Effect. All of the obligations, terms, provisions and releases set forth in this Agreement, shall be binding upon and inure to the benefit of LifeCell, the Client and their respective heir s, per sonal representatives, successors, and assigns.
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 18 of 45
Page 19 of 45
HLA match or pay up to US$ 25,000 (Twenty Five Thousand US Dollars only) subject to the following conditions:
11.
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. Such limitation of liability shall in no way be diminished as a result of the LifeCell Cares Program or in the event that liability arising from acts committed by LifeCell that are intentional and grossly negligent.
9.2.1. The Child or its Sibling must be positively diagnosed after the Enrolment date for a hematological malignancy treatable using the stored Specimen, and must be scheduled for a stem cell transplant. 9.2.2 The Specimen is lost due to change in temperature arising out of loss or damage to the cold storage machinery due to operation of an insured peril (i.e.) fire, lighting, explosion and implosion, aircraft damage, riot, strike, malicious damage and terrorism, storm, tempest and flood and inundation, impact damage, subsidence and landslide/rockslide, bursting and/or overflowing of water tanks, apparatus and pipes, missile testing, leakage from automatic sprinkler installation, bush fire, earthquake (fire and shock), and act of terrorism. 9.3
12.
Force Majeure: Client agrees that lifecell shall not be liable for any loss, deterioration or destruction of all or any part of the specimen resulting from causes or circumstances which are beyond LifeCell’s reasonable control.
3.
Indemnity to Hold Harmless. Client agrees to indemnify and hold LifeCell, its respective agents, employees, officers, directors, shareholders and affiliates harmless from any and all claims, liabilities, demands and causes of action asserted against them by any third party.
LifeCell Payment Guarantee: If the Client's Specimen upon retrieval for a hematopoietic stem cell transplant does not meet LifeCell's then prevailing viability criteria benchmarked against existing international best practices then LifeCell will use its best endeavors to find a unit of suitable HLA match to the Child or pay the Client upto US$ 25,000 (Twenty Five Thousand US Dollars only).
Limitation of Liability:
9.4.
General Conditions for LifeCell Client Benefit Programs:
14.
Termination of Agreement.
14.1
This Agreement may be terminated
14.1.1. by Client at any time prior to the collection of the Specimen, or
9.4.2. Payments would be made on appropriate verification of Client’s request by LifeCell.
14.1.2. by LifeCell if it has exercised its right to refuse Specimen storage for any reason, including the consequential act of Sample rejection as per clause 2.7, or
9.4.3. Upon payment (or providing a unit of suitable HLA match) Client would thereby discharge and release LifeCell from all its liabilities.
14.1.3. 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, or
10.
14.1.4. by mutual agreement of Client and LifeCell, or
9.4.1. The Client Agreement is valid and is in force.
Disclaimers. Neither LifeCell nor any of its officers, directors, shareholders, employees, agents or consultants have made any representations, guarantee, warranties or assurances, express or implied, to Client of any kind o t h e r than those disclosed herein LifeCell does not perform any medical services, give any medical advice, or otherwise perform any functions other t h a n t hose expr essl y indicat ed; Lif eCell expr essl y disclaims any responsibility to provide any other. services.
President, LifeCell International
14.1.5. by either party upon 60 days prior written notice to the other party hereto, or 14.1.6. in the event, the Specimen are retrieved for a transplant. However, if the Client retrieves only a portion of the Specimen the Agreement would survive and continue until the entire Specimen has been retrieved. 14.2
14.2.2. If the Agreement is terminated by LifeCell under Section 14.1.5, 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.
Effects of Termination:
Client's Initials
Husband's Initials
Birth Mother, if not Client
18.
Multiple Births.
19.
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. 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.
20.
Notice.
14.2.3. If the Agreement is terminated under Section 14.1.6 a pro-rated refund of the prepaid store fees will be made by LifeCell to the Client
20.1.
Any notice shall be sufficiently given if delivered in person or sent by express mail or by registered or certified mail, postage prepaid.
15.
20.2. Notice to LifeCell must be delivered to LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, Dubai Media City, P.O. Box. 502026, Dubai, United Arab Emirates.
Arbitration. All disputes arising out of or relating to this Agreement will be resolved by arbitration. The arbitration will take place in Dubai, UAE as per the applicable laws of UAE. All decisions of the arbitrator shall be final, binding, and conclusive and arbitration constitutes the only method of resolving disputes to this Agreement.
Y
P O C NT
CLIE
14.2.1. If the Agreement is terminated under Section 14.1.3, 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.
16.
Governing Law and Jurisdiction.
21.
CLIE
Confidentiality; Consent to Release. LifeCell acknowledges the confidential nature of the information provided by Client and, if different from the Client, the Birth Mother of the Child and agrees to use its reasonable best efforts to maintain the confidentiality of the information except as required by law or as permitted by this Agreement. Client and, if different, the Birth Mother of the Child hereby agree to the release of information to the hospital, laboratory or physician providing the services to the Client.
President, LifeCell International
Y
P O C NT
This Agreement is governed by, construed and interpreted in accordance with the local laws of Dubai, UAE. Any Judicial proceedings brought against either LifeCell or Client under this agreement will be brought in a competent court in Dubai, UAE. LifeCell and Client consent to the exclusive jurisdiction of the aforesaid courts and waive any objection to venue therein and irrevocably agree to be bound by any judgement rendered thereby in connection with this Agreement. 17.
20.3. Notice to Client will be delivered to the address set forth in the Enrollment form or as updated by client to LifeCell. Entire Agreement.
This Agreement and the exhibits hereto constitute the entire agreement between LifeCell, Client and, if different, the birth mother of the Child and supersedes any prior agreements or understandings, oral and written.
22.
Survival. All provisions which by their terms require performance after the termination of this Agreement will survive the termination of this Agreement.
23.
Binding Effect. All of the obligations, terms, provisions and releases set forth in this Agreement, shall be binding upon and inure to the benefit of LifeCell, the Client and their respective heir s, per sonal representatives, successors, and assigns.
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 18 of 45
Page 19 of 45
EXHIBIT - 3 CRM NO.:
24.
Severability.
25.
If any part of this Agreement is found to be invalid or unenforceable, such provision is deemed modified to the extent nece sary to make the Agreement enforceable, and this Agreement shall otherwise remain in full force and effect.
Headings. The headings in this Agreement are for reference purposes only and shall not affect the meaning or interpretation of this Agreement.
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.
I ACCEPT ALL TERMS AND CONDITIONS OF THIS AGREEMENT
Name and Signature of Mother/Legal Guardian
Name and Signature of Father/Legal Guardian
Name of Birth Mother if not the Client
Signature of Birth Mother if not the Client
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?
YES
NO
Date:
Y
P O C NT
CLIE
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 20 of 45
Page 21 of 45
EXHIBIT - 3 CRM NO.:
24.
Severability.
25.
If any part of this Agreement is found to be invalid or unenforceable, such provision is deemed modified to the extent nece sary to make the Agreement enforceable, and this Agreement shall otherwise remain in full force and effect.
Headings. The headings in this Agreement are for reference purposes only and shall not affect the meaning or interpretation of this Agreement.
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.
I ACCEPT ALL TERMS AND CONDITIONS OF THIS AGREEMENT
Name and Signature of Mother/Legal Guardian
Name and Signature of Father/Legal Guardian
Name of Birth Mother if not the Client
Signature of Birth Mother if not the Client
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?
YES
NO
Date:
Y
P O C NT
CLIE
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 20 of 45
Page 21 of 45
EXHIBIT - 4 CRM NO.:
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?
MATERNAL HEALTH HISTORY (NON-CLIENT BIRTH MOTHER)
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?
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.
Unexplained weight loss or night sweats?
a)
b.
Blue or purple spots in your mouth or skin?
Cancer, Diabetes, Hepatitis, Blood Disease, Bleeding problem, Heart Disease, Drug or Alcohol abuse.
c.
Swollen lymph nodes for more than one month?
b)
HIV/AIDS or a positive test for the HIV/AIDS virus, HTLV, Malaria, Chaga's Disease.
d.
White spots or unusual sores in your mouth?
c)
Stroke, Seizure or multiple sclerosis, Lung Disease, Kidney Disease, Liver Disease, Babesiosis, Genetic disorder.
e.
Cough that wont go away or shortness of breath?
2.
Do you currently have or are you being treated for any type of infection?
f.
Diarrhea that won't go away?
3.
g.
Fever of more than 100.5 F for more than 10 days?
Do you have, or have a family history of, Dementia, Degenerative or neurological disease, or Creutzfeld Jakob disease?
18.
Have you had significant exposure to any substance that may be transferred in toxic doses, such as lead, mercury and gold?
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?
Genetic Mother’s Name:.....................................................
For LifeCell Medical Team use only. Reviewed by:..................................................
Genetic Mother’s Signature:............................................... Date:..................................................................................
President, LifeCell International
Date:............................................................... Signature:........................................................
Client's Initials
Husband's Initials
Birth Mother, if not Client
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 22 of 45
Page 23 of 45
EXHIBIT - 4 CRM NO.:
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?
MATERNAL HEALTH HISTORY (NON-CLIENT BIRTH MOTHER)
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?
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.
Unexplained weight loss or night sweats?
a)
b.
Blue or purple spots in your mouth or skin?
Cancer, Diabetes, Hepatitis, Blood Disease, Bleeding problem, Heart Disease, Drug or Alcohol abuse.
c.
Swollen lymph nodes for more than one month?
b)
HIV/AIDS or a positive test for the HIV/AIDS virus, HTLV, Malaria, Chaga's Disease.
d.
White spots or unusual sores in your mouth?
c)
Stroke, Seizure or multiple sclerosis, Lung Disease, Kidney Disease, Liver Disease, Babesiosis, Genetic disorder.
e.
Cough that wont go away or shortness of breath?
2.
Do you currently have or are you being treated for any type of infection?
f.
Diarrhea that won't go away?
3.
g.
Fever of more than 100.5 F for more than 10 days?
Do you have, or have a family history of, Dementia, Degenerative or neurological disease, or Creutzfeld Jakob disease?
18.
Have you had significant exposure to any substance that may be transferred in toxic doses, such as lead, mercury and gold?
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?
Genetic Mother’s Name:.....................................................
For LifeCell Medical Team use only. Reviewed by:..................................................
Genetic Mother’s Signature:............................................... Date:..................................................................................
President, LifeCell International
Date:............................................................... Signature:........................................................
Client's Initials
Husband's Initials
Birth Mother, if not Client
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 22 of 45
Page 23 of 45
EXHIBIT - 5 13.
From 1980 through 1996 have you:
CONSENT OF NON-CLIENT BIRTH MOTHER FOR COLLECTION:
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?
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 and Maternal 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, limitations, risks, and discomfort of cellular donation and has had the opportunity to access donor advocacy service. Birth Mother 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.
17.
Have you experienced any of the following conditions that can be signs or symptoms of HIV/AIDS?
I have read the above information and hereby give the consent to perform the above required tests.
a.
Unexplained weight loss or night sweats?
Birth Mother’s Signature
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? .
Date: ……………………...............
Birth Mother’s Name: ………………….................................................................................................................. Gynaecologist’s Name:......................................................................................................................................... Gynaecologist’s Address……………………………...............................................................................................
EXHIBIT – 6 INFORMED CONSENT TO INFECTIOUS DISEASES & HIV TESTING: Birth Mother’s Name:.....................................................
For LifeCell Medical Team use only. Reviewed by:..................................................
Birth Mother’s Signature:............................................... Date:..................................................................................
Date:...............................................................
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.
Signature:........................................................
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 24 of 45
Page 25 of 45
EXHIBIT - 5 13.
From 1980 through 1996 have you:
CONSENT OF NON-CLIENT BIRTH MOTHER FOR COLLECTION:
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?
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 and Maternal 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, limitations, risks, and discomfort of cellular donation and has had the opportunity to access donor advocacy service. Birth Mother 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.
17.
Have you experienced any of the following conditions that can be signs or symptoms of HIV/AIDS?
I have read the above information and hereby give the consent to perform the above required tests.
a.
Unexplained weight loss or night sweats?
Birth Mother’s Signature
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? .
Date: ……………………...............
Birth Mother’s Name: ………………….................................................................................................................. Gynaecologist’s Name:......................................................................................................................................... Gynaecologist’s Address……………………………...............................................................................................
EXHIBIT – 6 INFORMED CONSENT TO INFECTIOUS DISEASES & HIV TESTING: Birth Mother’s Name:.....................................................
For LifeCell Medical Team use only. Reviewed by:..................................................
Birth Mother’s Signature:............................................... Date:..................................................................................
Date:...............................................................
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.
Signature:........................................................
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 24 of 45
Page 25 of 45
Screening for Infectious Diseases:
Released Parties for any reason relating to the collection of, or failure to collect, the cord blood, cord tissue, and the maternal blood samples.
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.
Birth Mother’s Signature .......................................................
I have read the above information and hereby give the consent to perform the above required tests.
Obstetrician / Gynaecologist Name: …………….......................................................................................................................................
Birth Mother’s Signature
Date: …………………….........................................
Date: ……………………...............
Birth Mother’s Name: …………………..................................................................................................................
Name of the mother……............................................................ Name of the father……............................................................... Expectant Father’s Signature...........................................
EXHIBIT – 8
Gynaecologist’s Name:.........................................................................................................................................
RISKS RELATING TO STEM CELL BANKING:
Gynaecologist’s Address.......................................................................................................................................
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.
EXHIBIT - 7 AUTHORIZATION TO COLLECT CORD BLOOD, CORD TISSUE AND MATERNAL BLOOD; RELEASE FROM LIABILITY The undersigned is participating in LifeCell ‘s BabyCord program. The program requires the collection of a sample of the Mother’s Blood and the collection of the umbilical cord tissue and umbilical cord blood at the time of birth of the Child. The collection procedure is outlined in LifeCell’s Umbilical Cord Blood and Cord Tissue Collection Instructions. Consent is hereby granted by the undersigned to the medical professionals attending to the birth to perform these collections. The undersigned acknowledges that complications may occur during which could prevent or impede the collection of the cord blood and / or cord tissue 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 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 and the maternal blood samples. 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
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
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. PROCESSING RISKS Samples upon receipt at the laboratory would be scheduled immediately for processing by trained staff in dedicated laboratories using validated processes, and appropriately qualified equipments and in compliance with statutory regulations. However in the rarest of rare conditions it is possible that during processing the sample may be either contaminated or may be partially or completely be lost either due to equipment failure or accident. Client understands that if the sample is contaminated the physician may refuse to utilize the sample for transplantation, or if the sample is lost it may not be available for transplant.
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 26 of 45
Page 27 of 45
Screening for Infectious Diseases:
Released Parties for any reason relating to the collection of, or failure to collect, the cord blood, cord tissue, and the maternal blood samples.
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.
Birth Mother’s Signature .......................................................
I have read the above information and hereby give the consent to perform the above required tests.
Obstetrician / Gynaecologist Name: …………….......................................................................................................................................
Birth Mother’s Signature
Date: …………………….........................................
Date: ……………………...............
Birth Mother’s Name: …………………..................................................................................................................
Name of the mother……............................................................ Name of the father……............................................................... Expectant Father’s Signature...........................................
EXHIBIT – 8
Gynaecologist’s Name:.........................................................................................................................................
RISKS RELATING TO STEM CELL BANKING:
Gynaecologist’s Address.......................................................................................................................................
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.
EXHIBIT - 7 AUTHORIZATION TO COLLECT CORD BLOOD, CORD TISSUE AND MATERNAL BLOOD; RELEASE FROM LIABILITY The undersigned is participating in LifeCell ‘s BabyCord program. The program requires the collection of a sample of the Mother’s Blood and the collection of the umbilical cord tissue and umbilical cord blood at the time of birth of the Child. The collection procedure is outlined in LifeCell’s Umbilical Cord Blood and Cord Tissue Collection Instructions. Consent is hereby granted by the undersigned to the medical professionals attending to the birth to perform these collections. The undersigned acknowledges that complications may occur during which could prevent or impede the collection of the cord blood and / or cord tissue 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 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 and the maternal blood samples. 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
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
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. PROCESSING RISKS Samples upon receipt at the laboratory would be scheduled immediately for processing by trained staff in dedicated laboratories using validated processes, and appropriately qualified equipments and in compliance with statutory regulations. However in the rarest of rare conditions it is possible that during processing the sample may be either contaminated or may be partially or completely be lost either due to equipment failure or accident. Client understands that if the sample is contaminated the physician may refuse to utilize the sample for transplantation, or if the sample is lost it may not be available for transplant.
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 26 of 45
Page 27 of 45
TESTING RISKS
APPLICATION 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.
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.
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.
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.
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.
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.
Name of the Client: ...................................
Client’s Signature:
Name of the Husband:...............................
Husband’s Signature:
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, non-maintenance of temperature due to poor refrigeration of foam bricks or performance of the dry shippers, improper packaging due to non-following 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.
Date:.........................................................
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
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 28 of 45
Page 29 of 45
TESTING RISKS
APPLICATION 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.
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.
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.
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.
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.
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.
Name of the Client: ...................................
Client’s Signature:
Name of the Husband:...............................
Husband’s Signature:
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, non-maintenance of temperature due to poor refrigeration of foam bricks or performance of the dry shippers, improper packaging due to non-following 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.
Date:.........................................................
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
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 28 of 45
Page 29 of 45
handling and transportation of such Menstrual blood at no additional costs to the Client. The Service Provider is not an agent of LifeCell and LifeCell shall not be responsible in any manner for the services rendered by the Service Provider.
MENSTRUAL BLOOD STEM CELL TESTING, PROCESSING AND STORAGE AGREEMENT 2.6.
I, the undersigned (the ‘Client’), on behalf of myself, engage LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, Dubai Media City, PO Box 502026, Dubai, UAE (‘LifeCell’), to process, test, and store stem cells obtained from the menstrual blood on the following terms (this ‘Agreement’). This Agreement is entered into this _________ day of ___________________, 201______ (the ‘Enrollment Date’) and legally binds LifeCell and the Client, including the legal heir of the client.
1. Definitions:
2.
In this Agreement, (including the recitals above), unless the context otherwise requires, the following expressions shall have the following meanings:
Services of LifeCell; Testing, Processing, Preserving and Storage.
2.1.
LifeCell offers its services under various options which the Client must choose from as detailed in Exhibit 2.
1.1.
2.2.
LifeCell shall obtain all statutory permissions and licenses that might be required for providing the services contemplated under this Agreement.
1.2.
1.3.
‘Client’ means the woman, from whom the menstrual blood sample has been collected. ‘Specimen’ means and includes stem cells obtained from menstrual blood. ‘Collection Kit’ means the kit consisting of all essential materials required for the purpose of collection and labeling of the Menstrual Blood and Specimen, such as Menstrual Blood Collection Tubes, Barcode labels, Foam Bricks, Alcohol Swabs, Hologram Stickers, Packing Instructions, Sealable Plastic Bags and Absorbent Paper Towels, and all packed in a certified transport container compliant with International Air Transport Association (IATA) regulations..
1.4.
‘LifeCell Laboratory’ means LifeCell's licensed and accredited laboratory facilities where the Specimen is processed, tested, and stored.
1.5.
‘Minimally Expanded Stem Cells’ means cells that have been obtained from ex-vivo isolation and not subjected to further passaging.
1.6.
‘Mesenchymal Stem Cells’ means multipotent stem cells that can differentiate into a variety of cell types and are characterized by expression of the markers CD90 and CD105.
President, LifeCell International
2.3.
LifeCell will provide the Client with the following immediately upon enrollment:
2.3.1.
A Collection Kit
2.3.2.
A copy of this Agreement
2.3.3.
A unique Client Relationship Management (CRM) identification number that enables the Client to quote for all communications with LifeCell.
2.4.
2.5.
Client must collect, prepare, and properly label the Specimen, in accordance with the instructions given in the collection kit. In particular the Client must ensure that a minimum of 10 milliliters of menstrual blood sample is collected, since smaller quantity of menstrual blood sample may not be suitable for processing. The client shall also ensure that the forms included in the collection Kit are duly filled up and sent to LifeCell. It is the responsibility of the Client for delivery of the menstrual blood sample to LifeCell’s Laboratory within 48 hours of collection of menstrual blood sample. LifeCell at the request of the Client would arrange for pick-up of the Specimen from the Client’s Place to LifeCell Laboratory, using a certified Service Provider who has the required expertise in
Client's Initials
2.7.
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 including but not limited to cell counts, sterility and viability.
5.3.
If the Client consents her willingness to continue the storage after the Client attain s the age of 60, the Client shall enter into a new Agreement with LifeCell as per the then prevailing terms and storage fee.
6.
Representations and Warranties of Client. Client represents and warrants that
6.1.
Client has had the opportunity to consult Client's own legal counsel to review this Agreement and related forms and Client has carefully read and understood all the terms of this Agreement;
6.2.
The decision to collect the Specimen, test and process and store the Specimen is a completely voluntary act of Client.
In the event that the Specimen is determined by LifeCell to be unfit for processing and / or storage for any reason, such as insufficient volume, low cell count / viability, microbial contamination of Specimen, etc., then LifeCell will notify the Client immediately, and seek instructions for disposition of the Specimen. If LifeCell does not receive written instructions within 60 days of such notice then LifeCell has the right to terminate the Agreement and destroy the Specimen without further liability.
6.3.
Client has discussed with a competent medical professional, who is not an employee or agent of LifeCell, regarding the collection, processing, storage and possible future use of the Specimen, including possible risks as laid out in Exhibit 8.
7.
Obligations and Rights to Specimen.
3.
Client Responsibilities.
7.1.
3.1.
The Client must complete the Enrollment Form (Exhibit 1), the Health History (Exhibit 3), and make due payment of fees.
Client is solely liable for all of the obligations and responsibilities herein under and shall have all rights of the Clients, including control of the Specimen. The exercise of any rights and control over the Specimen will require written notice to LifeCell signed by the Client.
3.2.
Client must promptly notify LifeCell in writing of any change in Client's name or current mailing address or in the legal guardian of the Client.
7.2.
Any components that remain after the Specimen is processed and that are not being stored, will be disposed off by LifeCell.
4.
Fees for Services.
8.
Retrieval of Specimen:
4.1.
One-time Storage Plan. Pursuant to the One - time Storage Plan, Client makes a one-time payment which includes the processing and testing Fee and storage of the Specimen until the Client attains the age of 60.
8.1.
There is no fee payable by the Client to LifeCell for retrieval of Specimen.
8.2.
The stored Specimen will be available for access or delivery by or before the end of the 7th business day after LifeCell's receipt of a written request from Client. However if the Client’s chosen plan also covers isolation and expansion of stem cells at the time of retrieval, the expanded cells would be available for access or delivery by or before the end of 90th business day after LifeCell’s receipt of a written request from Client.
8.3.
The request must be made on a request form provided by LifeCell. This must be signed by the Client, and provide the name and address of the facility where the Specimen is to be delivered and the date of delivery is requested.
4.2.
All fees paid by Client to LifeCell are non-r e f u n d a b l e . However in the event of the Specimen being unfit for processing, the processing and storage fees would be refunded, and in case the Specimen is found to be unfit for storage, the storage fees would be refunded.
5.
Terms of Agreement.
5.1.
This agreement will continue until the Client attains the age of 60.
5.2.
LifeCell will make reasonable attempts to notify the Client about the scheduled expiry of this Agreement at least 60 days in advance before the Client attains the age of 60.
President, LifeCell International
Client's Initials
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 30 of 45
Page 31 of 45
handling and transportation of such Menstrual blood at no additional costs to the Client. The Service Provider is not an agent of LifeCell and LifeCell shall not be responsible in any manner for the services rendered by the Service Provider.
MENSTRUAL BLOOD STEM CELL TESTING, PROCESSING AND STORAGE AGREEMENT 2.6.
I, the undersigned (the ‘Client’), on behalf of myself, engage LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, Dubai Media City, PO Box 502026, Dubai, UAE (‘LifeCell’), to process, test, and store stem cells obtained from the menstrual blood on the following terms (this ‘Agreement’). This Agreement is entered into this _________ day of ___________________, 201______ (the ‘Enrollment Date’) and legally binds LifeCell and the Client, including the legal heir of the client.
1. Definitions:
2.
In this Agreement, (including the recitals above), unless the context otherwise requires, the following expressions shall have the following meanings:
Services of LifeCell; Testing, Processing, Preserving and Storage.
2.1.
LifeCell offers its services under various options which the Client must choose from as detailed in Exhibit 2.
1.1.
2.2.
LifeCell shall obtain all statutory permissions and licenses that might be required for providing the services contemplated under this Agreement.
1.2.
1.3.
‘Client’ means the woman, from whom the menstrual blood sample has been collected. ‘Specimen’ means and includes stem cells obtained from menstrual blood. ‘Collection Kit’ means the kit consisting of all essential materials required for the purpose of collection and labeling of the Menstrual Blood and Specimen, such as Menstrual Blood Collection Tubes, Barcode labels, Foam Bricks, Alcohol Swabs, Hologram Stickers, Packing Instructions, Sealable Plastic Bags and Absorbent Paper Towels, and all packed in a certified transport container compliant with International Air Transport Association (IATA) regulations..
1.4.
‘LifeCell Laboratory’ means LifeCell's licensed and accredited laboratory facilities where the Specimen is processed, tested, and stored.
1.5.
‘Minimally Expanded Stem Cells’ means cells that have been obtained from ex-vivo isolation and not subjected to further passaging.
1.6.
‘Mesenchymal Stem Cells’ means multipotent stem cells that can differentiate into a variety of cell types and are characterized by expression of the markers CD90 and CD105.
President, LifeCell International
2.3.
LifeCell will provide the Client with the following immediately upon enrollment:
2.3.1.
A Collection Kit
2.3.2.
A copy of this Agreement
2.3.3.
A unique Client Relationship Management (CRM) identification number that enables the Client to quote for all communications with LifeCell.
2.4.
2.5.
Client must collect, prepare, and properly label the Specimen, in accordance with the instructions given in the collection kit. In particular the Client must ensure that a minimum of 10 milliliters of menstrual blood sample is collected, since smaller quantity of menstrual blood sample may not be suitable for processing. The client shall also ensure that the forms included in the collection Kit are duly filled up and sent to LifeCell. It is the responsibility of the Client for delivery of the menstrual blood sample to LifeCell’s Laboratory within 48 hours of collection of menstrual blood sample. LifeCell at the request of the Client would arrange for pick-up of the Specimen from the Client’s Place to LifeCell Laboratory, using a certified Service Provider who has the required expertise in
Client's Initials
2.7.
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 including but not limited to cell counts, sterility and viability.
5.3.
If the Client consents her willingness to continue the storage after the Client attain s the age of 60, the Client shall enter into a new Agreement with LifeCell as per the then prevailing terms and storage fee.
6.
Representations and Warranties of Client. Client represents and warrants that
6.1.
Client has had the opportunity to consult Client's own legal counsel to review this Agreement and related forms and Client has carefully read and understood all the terms of this Agreement;
6.2.
The decision to collect the Specimen, test and process and store the Specimen is a completely voluntary act of Client.
In the event that the Specimen is determined by LifeCell to be unfit for processing and / or storage for any reason, such as insufficient volume, low cell count / viability, microbial contamination of Specimen, etc., then LifeCell will notify the Client immediately, and seek instructions for disposition of the Specimen. If LifeCell does not receive written instructions within 60 days of such notice then LifeCell has the right to terminate the Agreement and destroy the Specimen without further liability.
6.3.
Client has discussed with a competent medical professional, who is not an employee or agent of LifeCell, regarding the collection, processing, storage and possible future use of the Specimen, including possible risks as laid out in Exhibit 8.
7.
Obligations and Rights to Specimen.
3.
Client Responsibilities.
7.1.
3.1.
The Client must complete the Enrollment Form (Exhibit 1), the Health History (Exhibit 3), and make due payment of fees.
Client is solely liable for all of the obligations and responsibilities herein under and shall have all rights of the Clients, including control of the Specimen. The exercise of any rights and control over the Specimen will require written notice to LifeCell signed by the Client.
3.2.
Client must promptly notify LifeCell in writing of any change in Client's name or current mailing address or in the legal guardian of the Client.
7.2.
Any components that remain after the Specimen is processed and that are not being stored, will be disposed off by LifeCell.
4.
Fees for Services.
8.
Retrieval of Specimen:
4.1.
One-time Storage Plan. Pursuant to the One - time Storage Plan, Client makes a one-time payment which includes the processing and testing Fee and storage of the Specimen until the Client attains the age of 60.
8.1.
There is no fee payable by the Client to LifeCell for retrieval of Specimen.
8.2.
The stored Specimen will be available for access or delivery by or before the end of the 7th business day after LifeCell's receipt of a written request from Client. However if the Client’s chosen plan also covers isolation and expansion of stem cells at the time of retrieval, the expanded cells would be available for access or delivery by or before the end of 90th business day after LifeCell’s receipt of a written request from Client.
8.3.
The request must be made on a request form provided by LifeCell. This must be signed by the Client, and provide the name and address of the facility where the Specimen is to be delivered and the date of delivery is requested.
4.2.
All fees paid by Client to LifeCell are non-r e f u n d a b l e . However in the event of the Specimen being unfit for processing, the processing and storage fees would be refunded, and in case the Specimen is found to be unfit for storage, the storage fees would be refunded.
5.
Terms of Agreement.
5.1.
This agreement will continue until the Client attains the age of 60.
5.2.
LifeCell will make reasonable attempts to notify the Client about the scheduled expiry of this Agreement at least 60 days in advance before the Client attains the age of 60.
President, LifeCell International
Client's Initials
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 30 of 45
Page 31 of 45
8.4.
8.5.
If the retrieval is requested for a transplant, the request form must be accompanied by transplant physician’s certification confirming the end-use. The stored Specimen can only be released for use in compliance with the statutory regulations at the place of transplant.
General Conditions:
9.3.1.
The Client Agreement is valid and is in force.
9.3.2.
Payments would be made on appropriate verification of Client’s request by LifeCell.
9.3.3.
Upon payment Client would thereby discharge and release LifeCell from all its liabilities.
10.
Disclaimers.
Free Worldwide Shipment: In the event of a transplant, the Specimen would be made available for transplantation in a special cryoshipper owned by LifeCell. For purposes of convenience, LifeCell on the request of the Client shall make necessary arrangements with a certified Service Provider who has the required expertise in handling and transportation of such Specimen at no additional costs to the Client. The Service Provider is not an agent of LifeCell and LifeCell shall not be responsible in any manner for the services rendered by the service provider.
9.
9.3.
11.
LifeCell Disaster Relief Program: While LifeCell shall ensure that the preserved Specimen will be maintained with utmost care, there may be unforeseen events that may occur, which are beyond the reasonable control of LifeCell, that may potentially deteriorate the Specimen during transit or whilst being held in cold storage premises. In the extremely unlikely occurrence of such event, LifeCell will pay up to USD 25000 (US Dollars Twenty Five Thousands Only) subject to the following conditions:
9.1.
The Client must be positively diagnosed after the Enrollment date, for a hematological malignancy treatable using the stored Specimen, and must be scheduled for a stem cell transplant.
9.2.
The Specimen is lost due to change in temperature arising out of loss or damage to the cryo preservation machinery due to operation of an insured peril (i.e) fire, lighting, explosion and implosion, aircraft damage, riot, strike, malicious damage and terrorism, storm, tempest and flood and inundation, impact damage, subsidence and landslide/rockslide, bursting and/ or overflowing of water tanks, apparatus and pipes, missile testing, leakage from automatic sprinkler installation, bush fire, earthquake (Fire and shock), and act of terrorism.
President, LifeCell International
14.1.2.
14.1.3.
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, or
14.1.4.
by mutual agreement of Client and LifeCell, or
14.1.5.
by either party upon 60 days prior written notice to the other party hereto, or
Neither LifeCell nor any of its officers, directors, shareholders, employees, agents or consultants have made any representations, guarantee, warranties or assurances, express or implied, to Client of any kind other than those disclosed herein LifeCell does not perform any medical services, give any medical advice, or otherwise perform any functions other than those expressly indicated; LifeCell expressly disclaims any responsibility to provide any other services.
14.1.6.
in the event, the Specimen are retrieved for a transplant. However, if the Client retrieves only a portion of the Specimen the Agreement would survive and continue until the entire Specimen has been retrieved.
14.2
Effects of Termination:
Limitation of Liability:
14.2.1.
If the Agreement is terminated under Section 14.1.3, 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 storin t h e 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.
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. Such limitation of liability shall in no way be diminished as a result of the LifeCell Cares Program or in the event that liability arising from acts committed by LifeCell that are intentional and grossly negligent. 12.
14.2.2.
Force Majeure: Client agrees that LifeCell shall not be liable for any loss, deterioration or destruction of all or any part of the specimen resulting from causes or circumstances which are beyond LifeCell’s reasonable control.
13.
by LifeCell if it has exercised its right to refuse Specimen storage for any reason, including the consequential act of Sample rejection as per clause 2.7, or
14.2.3.
If the Agreement is terminated under Section 14.1.6 a pro-rated refund of the prepaid store fees will be made by LifeCell to the Client
15.
Arbitration.
Indemnity to Hold Harmless. Client agrees to indemnify and hold LifeCell, its respective agents, employees, officers, directors, shareholders and affiliates harmless from any and all claims, liabilities, demands and causes of action asserted against them by any third party.
14.
Termination of Agreement.
14.1
This Agreement may be terminated
14.1.1.
by Client at any time prior to the collection of the Specimen, or
Client's Initials
If the Agreement is terminated by LifeCell under Section 14.1.5, 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.
All disputes arising out of or relating to this Agreement will be resolved by arbitration. The arbitration will take place in Dubai, UAE as per the applicable laws of UAE. All decisions of the arbitrator shall be final, binding, and conclusive and arbitration constitutes the only method of resolving disputes to this Agreement.
President, LifeCell International
16.
Governing Law and Jurisdiction. This Agreement is governed by, construed and interpreted in accordance with the local laws of Dubai, UAE. Any Judicial proceedings brought against either LifeCell or Client under this agreement will be brought in a competent court in Dubai, UAE. LifeCell and Client consent to the exclusive jurisdiction of the aforesaid courts and waive any objection to venue therein and irrevocably agree to be bound by any judgement rendered thereby in connection with this Agreement.
17.
Confidentiality; Consent to Release. LifeCell acknowledges the confidential nature of the information provided by Client and agrees to use its reasonable best efforts to maintain the confidentiality of the information except as required by law or as permitted by this Agreement. Client hereby agree to the release of information to the hospital, laboratory or physician providing the services to the Client.
18.
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.
19.
Notice.
19.1.
Any notice shall be sufficiently given if delivered in person or sent by express mail or by registered or certified mail, postage prepaid.
19.2.
Notice to LifeCell must be delivered to LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, P.O. Box No 502026, Dubai Media City, Dubai, UAE.
19.3.
Notice to Client will be delivered to the address set forth in the Enrollment form or as updated by Client to LifeCell.
20.
Entire Agreement. This Agreement and the exhibits hereto constitute the entire agreement between LifeCell and the Client and supersedes any prior agreements or understandings, oral and written.
21.
Survival. All provisions which by their terms require performance after the termination of this Agreement will survive the termination of this Agreement.
Client's Initials
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 32 of 45
Page 33 of 45
8.4.
8.5.
If the retrieval is requested for a transplant, the request form must be accompanied by transplant physician’s certification confirming the end-use. The stored Specimen can only be released for use in compliance with the statutory regulations at the place of transplant.
General Conditions:
9.3.1.
The Client Agreement is valid and is in force.
9.3.2.
Payments would be made on appropriate verification of Client’s request by LifeCell.
9.3.3.
Upon payment Client would thereby discharge and release LifeCell from all its liabilities.
10.
Disclaimers.
Free Worldwide Shipment: In the event of a transplant, the Specimen would be made available for transplantation in a special cryoshipper owned by LifeCell. For purposes of convenience, LifeCell on the request of the Client shall make necessary arrangements with a certified Service Provider who has the required expertise in handling and transportation of such Specimen at no additional costs to the Client. The Service Provider is not an agent of LifeCell and LifeCell shall not be responsible in any manner for the services rendered by the service provider.
9.
9.3.
11.
LifeCell Disaster Relief Program: While LifeCell shall ensure that the preserved Specimen will be maintained with utmost care, there may be unforeseen events that may occur, which are beyond the reasonable control of LifeCell, that may potentially deteriorate the Specimen during transit or whilst being held in cold storage premises. In the extremely unlikely occurrence of such event, LifeCell will pay up to USD 25000 (US Dollars Twenty Five Thousands Only) subject to the following conditions:
9.1.
The Client must be positively diagnosed after the Enrollment date, for a hematological malignancy treatable using the stored Specimen, and must be scheduled for a stem cell transplant.
9.2.
The Specimen is lost due to change in temperature arising out of loss or damage to the cryo preservation machinery due to operation of an insured peril (i.e) fire, lighting, explosion and implosion, aircraft damage, riot, strike, malicious damage and terrorism, storm, tempest and flood and inundation, impact damage, subsidence and landslide/rockslide, bursting and/ or overflowing of water tanks, apparatus and pipes, missile testing, leakage from automatic sprinkler installation, bush fire, earthquake (Fire and shock), and act of terrorism.
President, LifeCell International
14.1.2.
14.1.3.
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, or
14.1.4.
by mutual agreement of Client and LifeCell, or
14.1.5.
by either party upon 60 days prior written notice to the other party hereto, or
Neither LifeCell nor any of its officers, directors, shareholders, employees, agents or consultants have made any representations, guarantee, warranties or assurances, express or implied, to Client of any kind other than those disclosed herein LifeCell does not perform any medical services, give any medical advice, or otherwise perform any functions other than those expressly indicated; LifeCell expressly disclaims any responsibility to provide any other services.
14.1.6.
in the event, the Specimen are retrieved for a transplant. However, if the Client retrieves only a portion of the Specimen the Agreement would survive and continue until the entire Specimen has been retrieved.
14.2
Effects of Termination:
Limitation of Liability:
14.2.1.
If the Agreement is terminated under Section 14.1.3, 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 storin t h e 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.
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. Such limitation of liability shall in no way be diminished as a result of the LifeCell Cares Program or in the event that liability arising from acts committed by LifeCell that are intentional and grossly negligent. 12.
14.2.2.
Force Majeure: Client agrees that LifeCell shall not be liable for any loss, deterioration or destruction of all or any part of the specimen resulting from causes or circumstances which are beyond LifeCell’s reasonable control.
13.
by LifeCell if it has exercised its right to refuse Specimen storage for any reason, including the consequential act of Sample rejection as per clause 2.7, or
14.2.3.
If the Agreement is terminated under Section 14.1.6 a pro-rated refund of the prepaid store fees will be made by LifeCell to the Client
15.
Arbitration.
Indemnity to Hold Harmless. Client agrees to indemnify and hold LifeCell, its respective agents, employees, officers, directors, shareholders and affiliates harmless from any and all claims, liabilities, demands and causes of action asserted against them by any third party.
14.
Termination of Agreement.
14.1
This Agreement may be terminated
14.1.1.
by Client at any time prior to the collection of the Specimen, or
Client's Initials
If the Agreement is terminated by LifeCell under Section 14.1.5, 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.
All disputes arising out of or relating to this Agreement will be resolved by arbitration. The arbitration will take place in Dubai, UAE as per the applicable laws of UAE. All decisions of the arbitrator shall be final, binding, and conclusive and arbitration constitutes the only method of resolving disputes to this Agreement.
President, LifeCell International
16.
Governing Law and Jurisdiction. This Agreement is governed by, construed and interpreted in accordance with the local laws of Dubai, UAE. Any Judicial proceedings brought against either LifeCell or Client under this agreement will be brought in a competent court in Dubai, UAE. LifeCell and Client consent to the exclusive jurisdiction of the aforesaid courts and waive any objection to venue therein and irrevocably agree to be bound by any judgement rendered thereby in connection with this Agreement.
17.
Confidentiality; Consent to Release. LifeCell acknowledges the confidential nature of the information provided by Client and agrees to use its reasonable best efforts to maintain the confidentiality of the information except as required by law or as permitted by this Agreement. Client hereby agree to the release of information to the hospital, laboratory or physician providing the services to the Client.
18.
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.
19.
Notice.
19.1.
Any notice shall be sufficiently given if delivered in person or sent by express mail or by registered or certified mail, postage prepaid.
19.2.
Notice to LifeCell must be delivered to LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, P.O. Box No 502026, Dubai Media City, Dubai, UAE.
19.3.
Notice to Client will be delivered to the address set forth in the Enrollment form or as updated by Client to LifeCell.
20.
Entire Agreement. This Agreement and the exhibits hereto constitute the entire agreement between LifeCell and the Client and supersedes any prior agreements or understandings, oral and written.
21.
Survival. All provisions which by their terms require performance after the termination of this Agreement will survive the termination of this Agreement.
Client's Initials
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 32 of 45
Page 33 of 45
22.
Binding Effect. 24. All of the obligations, terms, provisions and releases set forth in this Agreement, shall be binding upon and inure to the benefit of LifeCell, the Client, and their respective heirs, personal representatives, successors, and assigns.
23.
Headings. The headings in this Agreement are for reference purposes only and shall not affect the meaning or interpretation of this Agreement.
Severability.
MENSTRUAL BLOOD STEM CELL TESTING, PROCESSING AND STORAGE AGREEMENT I, the undersigned (the ‘Client’), on behalf of myself, engage LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, Dubai
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.
Media City, PO Box 502026, Dubai, UAE (‘LifeCell’), to process, test, and store stem cells obtained from the menstrual blood on the following terms (this ‘Agreement’). This Agreement is entered into this _________ day of ___________________, 201______ (the ‘Enrollment Date’) and legally binds LifeCell and the Client, including the legal heir of the client.
I ACCEPT ALL TERMS AND CONDITIONS OF THIS AGREEMENT
Date: Name and Signature of Client
1. Definitions:
2.
In this Agreement, (including the recitals above), unless the context otherwise requires, the following expressions shall have the following meanings:
Services of LifeCell; Testing, Processing, Preserving and Storage.
2.1.
LifeCell offers its services under various options which the Client must choose from as detailed in Exhibit 2.
‘Client’ means the woman, from whom the menstrual blood sample has been collected.
1.2.
‘Specimen’ means and includes stem cells obtained from menstrual blood.
1.3.
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
PY O C T
1.1.
2.2.
LifeCell shall obtain all statutory permissions and licenses that might be required for providing the services contemplated under this Agreement.
2.3.
LifeCell will provide the Client with the following immediately upon enrollment:
2.3.1.
A Collection Kit
2.3.2.
A copy of this Agreement
2.3.3.
A unique Client Relationship Management (CRM) identification number that enables the Client to quote for all communications with LifeCell.
2.4.
Client must collect, prepare, and properly label the Specimen, in accordance with the instructions given in the collection kit. In particular the Client must ensure that a minimum of 10 milliliters of menstrual blood sample is collected, since smaller quantity of menstrual blood sample may not be suitable for processing. The client shall also ensure that the forms included in the collection Kit are duly filled up and sent to LifeCell.
2.5.
It is the responsibility of the Client for delivery of the menstrual blood sample to LifeCell’s Laboratory within 48 hours of collection of menstrual blood sample. LifeCell at the request of the Client would arrange for pick-up of the Specimen from the Client’s Place to LifeCell Laboratory, using a certified Service Provider who has the required expertise in
N
CLIE
‘Collection Kit’ means the kit consisting of all essential materials required for the purpose of collection and labeling of the Menstrual Blood and Specimen, such as Menstrual Blood Collection Tubes, Barcode labels, Foam Bricks, Alcohol Swabs, Hologram Stickers, Packing Instructions, Sealable Plastic Bags and Absorbent Paper Towels, and all packed in a certified transport container compliant with International Air Transport Association (IATA) regulations..
1.4.
‘LifeCell Laboratory’ means LifeCell's licensed and accredited laboratory facilities where the Specimen is processed, tested, and stored.
1.5.
‘Minimally Expanded Stem Cells’ means cells that have been obtained from ex-vivo isolation and not subjected to further passaging.
1.6.
‘Mesenchymal Stem Cells’ means multipotent stem cells that can differentiate into a variety of cell types and are characterized by expression of the markers CD90 and CD105.
President, LifeCell International
Client's Initials
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 34 of 45
Page 35 of 45
22.
Binding Effect. 24. All of the obligations, terms, provisions and releases set forth in this Agreement, shall be binding upon and inure to the benefit of LifeCell, the Client, and their respective heirs, personal representatives, successors, and assigns.
23.
Headings. The headings in this Agreement are for reference purposes only and shall not affect the meaning or interpretation of this Agreement.
Severability.
MENSTRUAL BLOOD STEM CELL TESTING, PROCESSING AND STORAGE AGREEMENT I, the undersigned (the ‘Client’), on behalf of myself, engage LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, Dubai
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.
Media City, PO Box 502026, Dubai, UAE (‘LifeCell’), to process, test, and store stem cells obtained from the menstrual blood on the following terms (this ‘Agreement’). This Agreement is entered into this _________ day of ___________________, 201______ (the ‘Enrollment Date’) and legally binds LifeCell and the Client, including the legal heir of the client.
I ACCEPT ALL TERMS AND CONDITIONS OF THIS AGREEMENT
Date: Name and Signature of Client
1. Definitions:
2.
In this Agreement, (including the recitals above), unless the context otherwise requires, the following expressions shall have the following meanings:
Services of LifeCell; Testing, Processing, Preserving and Storage.
2.1.
LifeCell offers its services under various options which the Client must choose from as detailed in Exhibit 2.
‘Client’ means the woman, from whom the menstrual blood sample has been collected.
1.2.
‘Specimen’ means and includes stem cells obtained from menstrual blood.
1.3.
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
PY O C T
1.1.
2.2.
LifeCell shall obtain all statutory permissions and licenses that might be required for providing the services contemplated under this Agreement.
2.3.
LifeCell will provide the Client with the following immediately upon enrollment:
2.3.1.
A Collection Kit
2.3.2.
A copy of this Agreement
2.3.3.
A unique Client Relationship Management (CRM) identification number that enables the Client to quote for all communications with LifeCell.
2.4.
Client must collect, prepare, and properly label the Specimen, in accordance with the instructions given in the collection kit. In particular the Client must ensure that a minimum of 10 milliliters of menstrual blood sample is collected, since smaller quantity of menstrual blood sample may not be suitable for processing. The client shall also ensure that the forms included in the collection Kit are duly filled up and sent to LifeCell.
2.5.
It is the responsibility of the Client for delivery of the menstrual blood sample to LifeCell’s Laboratory within 48 hours of collection of menstrual blood sample. LifeCell at the request of the Client would arrange for pick-up of the Specimen from the Client’s Place to LifeCell Laboratory, using a certified Service Provider who has the required expertise in
N
CLIE
‘Collection Kit’ means the kit consisting of all essential materials required for the purpose of collection and labeling of the Menstrual Blood and Specimen, such as Menstrual Blood Collection Tubes, Barcode labels, Foam Bricks, Alcohol Swabs, Hologram Stickers, Packing Instructions, Sealable Plastic Bags and Absorbent Paper Towels, and all packed in a certified transport container compliant with International Air Transport Association (IATA) regulations..
1.4.
‘LifeCell Laboratory’ means LifeCell's licensed and accredited laboratory facilities where the Specimen is processed, tested, and stored.
1.5.
‘Minimally Expanded Stem Cells’ means cells that have been obtained from ex-vivo isolation and not subjected to further passaging.
1.6.
‘Mesenchymal Stem Cells’ means multipotent stem cells that can differentiate into a variety of cell types and are characterized by expression of the markers CD90 and CD105.
President, LifeCell International
Client's Initials
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 34 of 45
Page 35 of 45
handling and transportation of such Menstrual blood at no additional costs to the Client. The Service Provider is not an agent of LifeCell and LifeCell shall not be responsible in any manner for the services rendered by the Service Provider. 2.6.
2.7.
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 including but not limited to cell counts, sterility and viability.
5.3.
6.
If the Client consents her willingness to continue the storage after the Client attain s the age of 60, the Client shall enter into a new Agreement with LifeCell as per the then prevailing terms and storage fee. Representations and Warranties of Client.
6.1.
Client has had the opportunity to consult Client's own legal counsel to review this Agreement and related forms and Client has carefully read and understood all the terms of this Agreement;
7.
Obligations and Rights to Specimen.
3.
Client Responsibilities.
7.1.
3.1.
The Client must complete the Enrollment Form (Exhibit 1), the Health History (Exhibit 3), and make due payment of fees.
Client is solely liable for all of the obligations and responsibilities herein under and shall have all rights of the Clients, including control of the Specimen. The exercise of any rights and control over the Specimen will require written notice to LifeCell signed by the Client.
The decision to collect the Specimen, test and process and store the Specimen is a completely voluntary act of Client.
6.3.
Client has discussed with a competent medical professional, who is not an employee or agent of LifeCell, regarding the collection, processing, storage and possible future use of the Specimen, including possible risks as laid out in Exhibit 8.
CLIE
Client must promptly notify LifeCell in writing of any change in Client's name or current mailing address or in the legal guardian of the Client.
4.
Fees for Services.
4.1.
One-time Storage Plan. Pursuant to the One - time Storage Plan, Client makes a one-time payment which includes the processing and testing Fee and storage of the Specimen until the Client attains the age of 60.
7.2.
While LifeCell shall ensure that the preserved Specimen will be maintained with utmost care, there may be unforeseen events that may occur, which are beyond the reasonable control of LifeCell, that may potentially deteriorate the Specimen during transit or whilst being held in cold storage premises. In the extremely unlikely occurrence of such event, LifeCell will pay up to USD 25000 (US Dollars Twenty Five Thousands Only) subject to the following conditions:
There is no fee payable by the Client to LifeCell for retrieval of Specimen.
8.2.
The stored Specimen will be available for access or delivery by or before the end of the 7th business day after LifeCell's receipt of a written request from Client. However if the Client’s chosen plan also covers isolation and expansion of stem cells at the time of retrieval, the expanded cells would be available for access or delivery by or before the end of 90th business day after LifeCell’s receipt of a written request from Client.
Terms of Agreement.
5.1.
This agreement will continue until the Client attains the age of 60. LifeCell will make reasonable attempts to notify the Client about the scheduled expiry of this Agreement at least 60 days in advance before the Client attains the age of 60.
President, LifeCell International
8.3.
The request must be made on a request form provided by LifeCell. This must be signed by the Client, and provide the name and address of the facility where the Specimen is to be delivered and the date of delivery is requested.
Client's Initials
9.3.1.
The Client Agreement is valid and is in force.
9.3.2.
Payments would be made on appropriate verification of Client’s request by LifeCell.
9.3.3.
Upon payment Client would thereby discharge and release LifeCell from all its liabilities.
10.
Disclaimers. Neither LifeCell nor any of its officers, directors, shareholders, employees, agents or consultants have made any representations, guarantee, warranties or assurances, express or implied, to Client of any kind other than those disclosed herein LifeCell does not perform any medical services, give any medical advice, or otherwise perform any functions other than those expressly indicated; LifeCell expressly disclaims any responsibility to provide any other services.
11.
Limitation of Liability: 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. Such limitation of liability shall in no way be diminished as a result of the LifeCell Cares Program or in the event that liability arising from acts committed by LifeCell that are intentional and grossly negligent.
Y
P O C NT
CLIE
Any components that remain after the Specimen is processed and that are not being stored, will be disposed off by LifeCell.
8.1.
General Conditions:
LifeCell Disaster Relief Program:
Y
Retrieval of Specimen:
9.3.
Free Worldwide Shipment: In the event of a transplant, the Specimen would be made available for transplantation in a special cryoshipper owned by LifeCell. For purposes of convenience, LifeCell on the request of the Client shall make necessary arrangements with a certified Service Provider who has the required expertise in handling and transportation of such Specimen at no additional costs to the Client. The Service Provider is not an agent of LifeCell and LifeCell shall not be responsible in any manner for the services rendered by the service provider.
9.
8.
All fees paid by Client to LifeCell are non-r e f u n d a b l e . However in the event of the Specimen being unfit for processing, the processing and storage fees would be refunded, and in case the Specimen is found to be unfit for storage, the storage fees would be refunded.
5.
5.2.
6.2.
8.5.
P O C NT
3.2.
If the retrieval is requested for a transplant, the request form must be accompanied by transplant physician’s certification confirming the end-use. The stored Specimen can only be released for use in compliance with the statutory regulations at the place of transplant.
Client represents and warrants that
In the event that the Specimen is determined by LifeCell to be unfit for processing and / or storage for any reason, such as insufficient volume, low cell count / viability, microbial contamination of Specimen, etc., then LifeCell will notify the Client immediately, and seek instructions for disposition of the Specimen. If LifeCell does not receive written instructions within 60 days of such notice then LifeCell has the right to terminate the Agreement and destroy the Specimen without further liability.
4.2.
8.4.
9.1.
The Client must be positively diagnosed after the Enrollment date, for a hematological malignancy treatable using the stored Specimen, and must be scheduled for a stem cell transplant.
9.2.
The Specimen is lost due to change in temperature arising out of loss or damage to the cryo preservation machinery due to operation of an insured peril (i.e) fire, lighting, explosion and implosion, aircraft damage, riot, strike, malicious damage and terrorism, storm, tempest and flood and inundation, impact damage, subsidence and landslide/rockslide, bursting and/ or overflowing of water tanks, apparatus and pipes, missile testing, leakage from automatic sprinkler installation, bush fire, earthquake (Fire and shock), and act of terrorism.
President, LifeCell International
12.
Force Majeure: Client agrees that LifeCell shall not be liable for any loss, deterioration or destruction of all or any part of the specimen resulting from causes or circumstances which are beyond LifeCell’s reasonable control.
13.
Indemnity to Hold Harmless. Client agrees to indemnify and hold LifeCell, its respective agents, employees, officers, directors, shareholders and affiliates harmless from any and all claims, liabilities, demands and causes of action asserted against them by any third party.
14.
Termination of Agreement.
14.1
This Agreement may be terminated
14.1.1.
by Client at any time prior to the collection of the Specimen, or
Client's Initials
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 36 of 45
Page 37 of 45
handling and transportation of such Menstrual blood at no additional costs to the Client. The Service Provider is not an agent of LifeCell and LifeCell shall not be responsible in any manner for the services rendered by the Service Provider. 2.6.
2.7.
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 including but not limited to cell counts, sterility and viability.
5.3.
6.
If the Client consents her willingness to continue the storage after the Client attain s the age of 60, the Client shall enter into a new Agreement with LifeCell as per the then prevailing terms and storage fee. Representations and Warranties of Client.
6.1.
Client has had the opportunity to consult Client's own legal counsel to review this Agreement and related forms and Client has carefully read and understood all the terms of this Agreement;
7.
Obligations and Rights to Specimen.
3.
Client Responsibilities.
7.1.
3.1.
The Client must complete the Enrollment Form (Exhibit 1), the Health History (Exhibit 3), and make due payment of fees.
Client is solely liable for all of the obligations and responsibilities herein under and shall have all rights of the Clients, including control of the Specimen. The exercise of any rights and control over the Specimen will require written notice to LifeCell signed by the Client.
The decision to collect the Specimen, test and process and store the Specimen is a completely voluntary act of Client.
6.3.
Client has discussed with a competent medical professional, who is not an employee or agent of LifeCell, regarding the collection, processing, storage and possible future use of the Specimen, including possible risks as laid out in Exhibit 8.
CLIE
Client must promptly notify LifeCell in writing of any change in Client's name or current mailing address or in the legal guardian of the Client.
4.
Fees for Services.
4.1.
One-time Storage Plan. Pursuant to the One - time Storage Plan, Client makes a one-time payment which includes the processing and testing Fee and storage of the Specimen until the Client attains the age of 60.
7.2.
While LifeCell shall ensure that the preserved Specimen will be maintained with utmost care, there may be unforeseen events that may occur, which are beyond the reasonable control of LifeCell, that may potentially deteriorate the Specimen during transit or whilst being held in cold storage premises. In the extremely unlikely occurrence of such event, LifeCell will pay up to USD 25000 (US Dollars Twenty Five Thousands Only) subject to the following conditions:
There is no fee payable by the Client to LifeCell for retrieval of Specimen.
8.2.
The stored Specimen will be available for access or delivery by or before the end of the 7th business day after LifeCell's receipt of a written request from Client. However if the Client’s chosen plan also covers isolation and expansion of stem cells at the time of retrieval, the expanded cells would be available for access or delivery by or before the end of 90th business day after LifeCell’s receipt of a written request from Client.
Terms of Agreement.
5.1.
This agreement will continue until the Client attains the age of 60. LifeCell will make reasonable attempts to notify the Client about the scheduled expiry of this Agreement at least 60 days in advance before the Client attains the age of 60.
President, LifeCell International
8.3.
The request must be made on a request form provided by LifeCell. This must be signed by the Client, and provide the name and address of the facility where the Specimen is to be delivered and the date of delivery is requested.
Client's Initials
9.3.1.
The Client Agreement is valid and is in force.
9.3.2.
Payments would be made on appropriate verification of Client’s request by LifeCell.
9.3.3.
Upon payment Client would thereby discharge and release LifeCell from all its liabilities.
10.
Disclaimers. Neither LifeCell nor any of its officers, directors, shareholders, employees, agents or consultants have made any representations, guarantee, warranties or assurances, express or implied, to Client of any kind other than those disclosed herein LifeCell does not perform any medical services, give any medical advice, or otherwise perform any functions other than those expressly indicated; LifeCell expressly disclaims any responsibility to provide any other services.
11.
Limitation of Liability: 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. Such limitation of liability shall in no way be diminished as a result of the LifeCell Cares Program or in the event that liability arising from acts committed by LifeCell that are intentional and grossly negligent.
Y
P O C NT
CLIE
Any components that remain after the Specimen is processed and that are not being stored, will be disposed off by LifeCell.
8.1.
General Conditions:
LifeCell Disaster Relief Program:
Y
Retrieval of Specimen:
9.3.
Free Worldwide Shipment: In the event of a transplant, the Specimen would be made available for transplantation in a special cryoshipper owned by LifeCell. For purposes of convenience, LifeCell on the request of the Client shall make necessary arrangements with a certified Service Provider who has the required expertise in handling and transportation of such Specimen at no additional costs to the Client. The Service Provider is not an agent of LifeCell and LifeCell shall not be responsible in any manner for the services rendered by the service provider.
9.
8.
All fees paid by Client to LifeCell are non-r e f u n d a b l e . However in the event of the Specimen being unfit for processing, the processing and storage fees would be refunded, and in case the Specimen is found to be unfit for storage, the storage fees would be refunded.
5.
5.2.
6.2.
8.5.
P O C NT
3.2.
If the retrieval is requested for a transplant, the request form must be accompanied by transplant physician’s certification confirming the end-use. The stored Specimen can only be released for use in compliance with the statutory regulations at the place of transplant.
Client represents and warrants that
In the event that the Specimen is determined by LifeCell to be unfit for processing and / or storage for any reason, such as insufficient volume, low cell count / viability, microbial contamination of Specimen, etc., then LifeCell will notify the Client immediately, and seek instructions for disposition of the Specimen. If LifeCell does not receive written instructions within 60 days of such notice then LifeCell has the right to terminate the Agreement and destroy the Specimen without further liability.
4.2.
8.4.
9.1.
The Client must be positively diagnosed after the Enrollment date, for a hematological malignancy treatable using the stored Specimen, and must be scheduled for a stem cell transplant.
9.2.
The Specimen is lost due to change in temperature arising out of loss or damage to the cryo preservation machinery due to operation of an insured peril (i.e) fire, lighting, explosion and implosion, aircraft damage, riot, strike, malicious damage and terrorism, storm, tempest and flood and inundation, impact damage, subsidence and landslide/rockslide, bursting and/ or overflowing of water tanks, apparatus and pipes, missile testing, leakage from automatic sprinkler installation, bush fire, earthquake (Fire and shock), and act of terrorism.
President, LifeCell International
12.
Force Majeure: Client agrees that LifeCell shall not be liable for any loss, deterioration or destruction of all or any part of the specimen resulting from causes or circumstances which are beyond LifeCell’s reasonable control.
13.
Indemnity to Hold Harmless. Client agrees to indemnify and hold LifeCell, its respective agents, employees, officers, directors, shareholders and affiliates harmless from any and all claims, liabilities, demands and causes of action asserted against them by any third party.
14.
Termination of Agreement.
14.1
This Agreement may be terminated
14.1.1.
by Client at any time prior to the collection of the Specimen, or
Client's Initials
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 36 of 45
Page 37 of 45
14.1.2.
14.1.3.
by LifeCell if it has exercised its right to refuse Specimen storage for any reason, including the consequential act of Sample rejection as per clause 2.7, or
16.
by mutual agreement of Client and LifeCell, or
14.1.5.
by either party upon 60 days prior written notice to the other party hereto, or
14.1.6.
in the event, the Specimen are retrieved for a transplant. However, if the Client retrieves only a portion of the Specimen the Agreement would survive and continue until the entire Specimen has been retrieved.
14.2
Effects of Termination:
14.2.1.
If the Agreement is terminated under Section 14.1.3, 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 storin t h e 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.
17.
Confidentiality; Consent to Release. LifeCell acknowledges the confidential nature of the information provided by Client and agrees to use its reasonable best efforts to maintain the confidentiality of the information except as required by law or as permitted by this Agreement. Client hereby agree to the release of information to the hospital, laboratory or physician providing the services to the Client.
18.
Binding Effect. 24.
This Agreement is governed by, construed and interpreted in accordance with the local laws of Dubai, UAE. Any Judicial proceedings brought against either LifeCell or Client under this agreement will be brought in a competent court in Dubai, UAE. LifeCell and Client consent to the exclusive jurisdiction of the aforesaid courts and waive any objection to venue therein and irrevocably agree to be bound by any judgement rendered thereby in connection with this Agreement.
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, or
14.1.4.
22.
Governing Law and Jurisdiction.
All of the obligations, terms, provisions and releases set forth in this Agreement, shall be binding upon and inure to the benefit of LifeCell, the Client, and their respective heirs, personal representatives, successors, and assigns. 23.
14.2.2.
If the Agreement is terminated by LifeCell under Section 14.1.5, 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.
14.2.3.
If the Agreement is terminated under Section 14.1.6 a pro-rated refund of the prepaid store fees will be made by LifeCell to the Client
15.
Arbitration. All disputes arising out of or relating to this Agreement will be resolved by arbitration. The arbitration will take place in Dubai, UAE as per the applicable laws of UAE. All decisions of the arbitrator shall be final, binding, and conclusive and arbitration constitutes the only method of resolving disputes to this Agreement.
President, LifeCell International
The headings in this Agreement are for reference purposes only and shall not affect the meaning or interpretation of this Agreement.
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
Assignment.
Date:
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.
Name and Signature of Client
Y
Y
P O C NT
P O C NT
CLIE
Headings.
19.
Notice.
19.1.
Any notice shall be sufficiently given if delivered in person or sent by express mail or by registered or certified mail, postage prepaid.
19.2.
Notice to LifeCell must be delivered to LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, P.O. Box No 502026, Dubai Media City, Dubai, UAE.
19.3.
Notice to Client will be delivered to the address set forth in the Enrollment form or as updated by Client to LifeCell.
20.
Entire Agreement.
CLIE
This Agreement and the exhibits hereto constitute the entire agreement between LifeCell and the Client and supersedes any prior agreements or understandings, oral and written. 21.
Survival. All provisions which by their terms require performance after the termination of this Agreement will survive the termination of this Agreement.
Client's Initials
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 38 of 45
Page 39 of 45
14.1.2.
14.1.3.
by LifeCell if it has exercised its right to refuse Specimen storage for any reason, including the consequential act of Sample rejection as per clause 2.7, or
16.
by mutual agreement of Client and LifeCell, or
14.1.5.
by either party upon 60 days prior written notice to the other party hereto, or
14.1.6.
in the event, the Specimen are retrieved for a transplant. However, if the Client retrieves only a portion of the Specimen the Agreement would survive and continue until the entire Specimen has been retrieved.
14.2
Effects of Termination:
14.2.1.
If the Agreement is terminated under Section 14.1.3, 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 storin t h e 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.
17.
Confidentiality; Consent to Release. LifeCell acknowledges the confidential nature of the information provided by Client and agrees to use its reasonable best efforts to maintain the confidentiality of the information except as required by law or as permitted by this Agreement. Client hereby agree to the release of information to the hospital, laboratory or physician providing the services to the Client.
18.
Binding Effect. 24.
This Agreement is governed by, construed and interpreted in accordance with the local laws of Dubai, UAE. Any Judicial proceedings brought against either LifeCell or Client under this agreement will be brought in a competent court in Dubai, UAE. LifeCell and Client consent to the exclusive jurisdiction of the aforesaid courts and waive any objection to venue therein and irrevocably agree to be bound by any judgement rendered thereby in connection with this Agreement.
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, or
14.1.4.
22.
Governing Law and Jurisdiction.
All of the obligations, terms, provisions and releases set forth in this Agreement, shall be binding upon and inure to the benefit of LifeCell, the Client, and their respective heirs, personal representatives, successors, and assigns. 23.
14.2.2.
If the Agreement is terminated by LifeCell under Section 14.1.5, 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.
14.2.3.
If the Agreement is terminated under Section 14.1.6 a pro-rated refund of the prepaid store fees will be made by LifeCell to the Client
15.
Arbitration. All disputes arising out of or relating to this Agreement will be resolved by arbitration. The arbitration will take place in Dubai, UAE as per the applicable laws of UAE. All decisions of the arbitrator shall be final, binding, and conclusive and arbitration constitutes the only method of resolving disputes to this Agreement.
President, LifeCell International
The headings in this Agreement are for reference purposes only and shall not affect the meaning or interpretation of this Agreement.
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
Assignment.
Date:
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.
Name and Signature of Client
Y
Y
P O C NT
P O C NT
CLIE
Headings.
19.
Notice.
19.1.
Any notice shall be sufficiently given if delivered in person or sent by express mail or by registered or certified mail, postage prepaid.
19.2.
Notice to LifeCell must be delivered to LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, P.O. Box No 502026, Dubai Media City, Dubai, UAE.
19.3.
Notice to Client will be delivered to the address set forth in the Enrollment form or as updated by Client to LifeCell.
20.
Entire Agreement.
CLIE
This Agreement and the exhibits hereto constitute the entire agreement between LifeCell and the Client and supersedes any prior agreements or understandings, oral and written. 21.
Survival. All provisions which by their terms require performance after the termination of this Agreement will survive the termination of this Agreement.
Client's Initials
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 38 of 45
Page 39 of 45
APP. NO. ........................................... CRM NO.
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. TEMPORARY RECEIPT Receipt No: ..................................................
Date:
Received with thanks from Mr./Ms. ..........................................
..................................................................................................................................................
towards enrollment vide APP...No. ...........................................................................................a sum of Rs............................................................................. (Rupees.............................................................................................................................................................................................................................................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
LANK
TB
LEF Y L L NA
For LifeCell use only
For LifeCell International Private Limited
Y
P O C NT
Computer Receipt No :
TIO
AGE P S I TH
EN T N I S I
Authorised Signatory
CLIE
For LifeCell use only Payment received by
:
...........................................................................
Designation
:
...........................................................................
Center
:
...........................................................................
Center’s Tel. No.
:
...........................................................................
:
800 LIFECELL 800 54332355
:
+971 4 4494067
TOLL FREE HELPLINE
(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 Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 6 of 45
Page 41 of 45
APP. NO. ........................................... CRM NO.
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. TEMPORARY RECEIPT Receipt No: ..................................................
Date:
Received with thanks from Mr./Ms. ..........................................
..................................................................................................................................................
towards enrollment vide APP...No. ...........................................................................................a sum of Rs............................................................................. (Rupees.............................................................................................................................................................................................................................................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
LANK
TB
LEF Y L L NA
For LifeCell use only
For LifeCell International Private Limited
Y
P O C NT
Computer Receipt No :
TIO
AGE P S I TH
EN T N I S I
Authorised Signatory
CLIE
For LifeCell use only Payment received by
:
...........................................................................
Designation
:
...........................................................................
Center
:
...........................................................................
Center’s Tel. No.
:
...........................................................................
:
800 LIFECELL 800 54332355
:
+971 4 4494067
TOLL FREE HELPLINE
(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 Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 6 of 45
Page 41 of 45
CRM NO.
APP. NO. ...........................................
ACKNOWLEDGEMENT FOR POST DATED CHEQUE Mother’s Name
LifeCell Arabia Date of Enrolment
EMI Plan
Service Enrolled (Tick)
BABYCORD
BABYCORD DUO
PROTECT BABY PROTECT MOM
12 EMI
6 EMI
3 EMI
FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE.
BABYCORD USA
TEMPORARY RECEIPT Receipt No: ..................................................
Post-dated Instrument details
Received with thanks from Mr./Ms. ..........................................
We acknowledge receiving the following Post Dated Cheques from you towards part payment of umbilical cord stem cell banking of your child / children CHOOSE CURRENCY
AED
Date:
BHD
OMR
KWD
QAR
SAR
USD
SET I
..................................................................................................................................................
towards enrollment vide APP...No. ...........................................................................................a sum of Rs............................................................................. (Rupees.............................................................................................................................................................................................................................................Only) towards Enrollment/Processing/Storage fees by way of Cash/Credit Card/*Cheque/ *DD /EFT No.
Bank
Date...................................... Drawn on......................................................................................... Branch................................................ City..................................
Bank Branch
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date
Plan No. : ................................................................................................ Plan Name:.......................................................................................... EDD:.......................................................................................................... Amount per Cheque
SET II
*Cheque/DD Subject to realization
Note : A computer generated “Receipt” will be sent along with the Preservation certificate
Bank Bank Branch From Cheque No. To Cheque No.
SET III
Country
For LifeCell use only
Y
P O C NT
From Cheque Date
CLIE
For LifeCell International Private Limited
Computer Receipt No :
E T N E
To Cheque Date
C
Amount per Cheque
Bank Bank Branch
Y P O RC
Authorised Signatory
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date Amount per Cheque
SET IV Bank
For LifeCell use only
Bank Branch
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date Amount per Cheque
Total no. of cheques
Total Amount
Payment received by
:
...........................................................................
Designation
:
...........................................................................
Center
:
...........................................................................
Center’s Tel. No.
:
...........................................................................
:
800 LIFECELL 800 54332355
TOLL FREE
Total Amount in words
HELPLINE
:
(Name of the center incharge)
+971 4 4494067
Note: All the above cheques are considered valid only upon realization when presented on or after the respective dates.
Signature of the center incharge Name of LifeCell Executive LifeCell Authorised Signature Name of Signatory:
Employee Code
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 40 of 45
Page 43 of 45
CRM NO.
APP. NO. ...........................................
ACKNOWLEDGEMENT FOR POST DATED CHEQUE Mother’s Name
LifeCell Arabia Date of Enrolment
EMI Plan
Service Enrolled (Tick)
BABYCORD
BABYCORD DUO
PROTECT BABY PROTECT MOM
12 EMI
6 EMI
3 EMI
FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE.
BABYCORD USA
TEMPORARY RECEIPT Receipt No: ..................................................
Post-dated Instrument details
Received with thanks from Mr./Ms. ..........................................
We acknowledge receiving the following Post Dated Cheques from you towards part payment of umbilical cord stem cell banking of your child / children CHOOSE CURRENCY
AED
Date:
BHD
OMR
KWD
QAR
SAR
USD
SET I
..................................................................................................................................................
towards enrollment vide APP...No. ...........................................................................................a sum of Rs............................................................................. (Rupees.............................................................................................................................................................................................................................................Only) towards Enrollment/Processing/Storage fees by way of Cash/Credit Card/*Cheque/ *DD /EFT No.
Bank
Date...................................... Drawn on......................................................................................... Branch................................................ City..................................
Bank Branch
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date
Plan No. : ................................................................................................ Plan Name:.......................................................................................... EDD:.......................................................................................................... Amount per Cheque
SET II
*Cheque/DD Subject to realization
Note : A computer generated “Receipt” will be sent along with the Preservation certificate
Bank Bank Branch From Cheque No. To Cheque No.
SET III
Country
For LifeCell use only
Y
P O C NT
From Cheque Date
CLIE
For LifeCell International Private Limited
Computer Receipt No :
E T N E
To Cheque Date
C
Amount per Cheque
Bank Bank Branch
Y P O RC
Authorised Signatory
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date Amount per Cheque
SET IV Bank
For LifeCell use only
Bank Branch
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date Amount per Cheque
Total no. of cheques
Total Amount
Payment received by
:
...........................................................................
Designation
:
...........................................................................
Center
:
...........................................................................
Center’s Tel. No.
:
...........................................................................
:
800 LIFECELL 800 54332355
TOLL FREE
Total Amount in words
HELPLINE
:
(Name of the center incharge)
+971 4 4494067
Note: All the above cheques are considered valid only upon realization when presented on or after the respective dates.
Signature of the center incharge Name of LifeCell Executive LifeCell Authorised Signature Name of Signatory:
Employee Code
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 40 of 45
Page 43 of 45
CRM NO.
APP. NO. ...........................................
ACKNOWLEDGEMENT FOR POST DATED CHEQUE Mother’s Name
Date of Enrolment
EMI Plan
12 EMI
6 EMI
3 EMI
LifeCell International Private Limited Regd. Office :26, Vandalur-kelambakkam Road, Keelakottaiyur, Chennai - 600 048. TEMPORARY RECEIPT
Service Enrolled (Tick)
BABYCORD
BABYCORD DUO
PROTECT BABY PROTECT MOM
BABYCORD USA
Receipt No: ..................................................
Date:
Received with thanks from Mr./Ms. ..........................................
Post-dated Instrument details We acknowledge receiving the following Post Dated Cheques from you towards part payment of umbilical cord stem cell banking of your child / children
..................................................................................................................................................
towards enrollment vide APP...No. ...........................................................................................a sum of Rs............................................................................. (Rupees.............................................................................................................................................................................................................................................Only)
CHOOSE CURRENCY
AED
OMR
BHD
KWD
QAR
SAR
USD
SET I
towards Enrollment/Processing/Storage fees by way of Cash/Credit Card/*Cheque/ *DD /EFT No. Date...................................... Drawn on......................................................................................... Branch................................................ City..................................
Bank
Plan No. : ................................................................................................
Bank Branch
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date
Plan Name:.......................................................................................... EDD:.......................................................................................................... *Cheque/DD Subject to realization Amount per Cheque
SET II
Note : A computer generated “Receipt” will be sent along with the Preservation certificate
Bank Bank Branch From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date
SET III
For LifeCell use only
Country
PY O C R
NTE
CE
For LifeCell International Private Limited
Computer Receipt No :
Y P O LC
L ECE
LIF
Amount per Cheque
Authorised Signatory
Bank Bank Branch
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date Amount per Cheque
SET IV Bank
For LifeCell use only
Bank Branch
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date Amount per Cheque
Total no. of cheques
Total Amount
Payment received by
:
...........................................................................
Designation
:
...........................................................................
Center
:
...........................................................................
Center’s Tel. No.
:
...........................................................................
:
800 LIFECELL 800 54332355
TOLL FREE
Total Amount in words
HELPLINE
:
(Name of the center incharge)
+971 4 4494067
Note: All the above cheques are considered valid only upon realization when presented on or after the respective dates.
Signature of the center incharge Name of LifeCell Executive LifeCell Authorised Signature Name of Signatory:
Employee Code
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 40 of 45
Page 45 of 45
CRM NO.
APP. NO. ...........................................
ACKNOWLEDGEMENT FOR POST DATED CHEQUE Mother’s Name
Date of Enrolment
EMI Plan
12 EMI
6 EMI
3 EMI
LifeCell International Private Limited Regd. Office :26, Vandalur-kelambakkam Road, Keelakottaiyur, Chennai - 600 048. TEMPORARY RECEIPT
Service Enrolled (Tick)
BABYCORD
BABYCORD DUO
PROTECT BABY PROTECT MOM
BABYCORD USA
Receipt No: ..................................................
Date:
Received with thanks from Mr./Ms. ..........................................
Post-dated Instrument details We acknowledge receiving the following Post Dated Cheques from you towards part payment of umbilical cord stem cell banking of your child / children
..................................................................................................................................................
towards enrollment vide APP...No. ...........................................................................................a sum of Rs............................................................................. (Rupees.............................................................................................................................................................................................................................................Only)
CHOOSE CURRENCY
AED
OMR
BHD
KWD
QAR
SAR
USD
SET I
towards Enrollment/Processing/Storage fees by way of Cash/Credit Card/*Cheque/ *DD /EFT No. Date...................................... Drawn on......................................................................................... Branch................................................ City..................................
Bank
Plan No. : ................................................................................................
Bank Branch
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date
Plan Name:.......................................................................................... EDD:.......................................................................................................... *Cheque/DD Subject to realization Amount per Cheque
SET II
Note : A computer generated “Receipt” will be sent along with the Preservation certificate
Bank Bank Branch From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date
SET III
For LifeCell use only
Country
PY O C R
NTE
CE
For LifeCell International Private Limited
Computer Receipt No :
Y P O LC
L ECE
LIF
Amount per Cheque
Authorised Signatory
Bank Bank Branch
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date Amount per Cheque
SET IV Bank
For LifeCell use only
Bank Branch
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date Amount per Cheque
Total no. of cheques
Total Amount
Payment received by
:
...........................................................................
Designation
:
...........................................................................
Center
:
...........................................................................
Center’s Tel. No.
:
...........................................................................
:
800 LIFECELL 800 54332355
TOLL FREE
Total Amount in words
HELPLINE
:
(Name of the center incharge)
+971 4 4494067
Note: All the above cheques are considered valid only upon realization when presented on or after the respective dates.
Signature of the center incharge Name of LifeCell Executive LifeCell Authorised Signature Name of Signatory:
Employee Code
President, LifeCell International
Client's Initials
Husband's Initials
Birth Mother, if not Client
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
Page 40 of 45
Page 45 of 45
CRM NO.
ACKNOWLEDGEMENT FOR POST DATED CHEQUE Mother’s Name
Date of Enrolment
EMI Plan
Service Enrolled (Tick)
BABYCORD
BABYCORD DUO
PROTECT BABY PROTECT MOM
12 EMI
6 EMI
3 EMI
BABYCORD USA
Post-dated Instrument details We acknowledge receiving the following Post Dated Cheques from you towards part payment of umbilical cord stem cell banking of your child / children CHOOSE CURRENCY
AED
BHD
OMR
KWD
QAR
SAR
USD
SET I Bank Bank Branch
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date Amount per Cheque
SET II Bank Bank Branch From Cheque No. To Cheque No.
SET III
Country
From Cheque Date
Y P O LC
L
CE E F I L To Cheque Date
Amount per Cheque
Bank Bank Branch
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date Amount per Cheque
SET IV Bank Bank Branch
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date Amount per Cheque
Total no. of cheques
Total Amount
Total Amount in words
Note: All the above cheques are considered valid only upon realization when presented on or after the respective dates.
Name of LifeCell Executive LifeCell Authorised Signature Name of Signatory:
Employee Code
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com Page 40 of 45
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
CRM NO.
ACKNOWLEDGEMENT FOR POST DATED CHEQUE Mother’s Name
Date of Enrolment
EMI Plan
Service Enrolled (Tick)
BABYCORD
BABYCORD DUO
PROTECT BABY PROTECT MOM
12 EMI
6 EMI
3 EMI
BABYCORD USA
Post-dated Instrument details We acknowledge receiving the following Post Dated Cheques from you towards part payment of umbilical cord stem cell banking of your child / children CHOOSE CURRENCY
AED
BHD
OMR
KWD
QAR
SAR
USD
SET I Bank Bank Branch
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date Amount per Cheque
SET II Bank Bank Branch From Cheque No. To Cheque No.
SET III
Country
From Cheque Date
Y P O LC
L
CE E F I L To Cheque Date
Amount per Cheque
Bank Bank Branch
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date Amount per Cheque
SET IV Bank Bank Branch
Country
From Cheque No.
From Cheque Date
To Cheque No.
To Cheque Date Amount per Cheque
Total no. of cheques
Total Amount
Total Amount in words
Note: All the above cheques are considered valid only upon realization when presented on or after the respective dates.
Name of LifeCell Executive LifeCell Authorised Signature Name of Signatory:
Employee Code
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com Page 40 of 45
LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE. | +971 4 4494067 | www.lifecellinternational.com
800 LIFECELL TOLL FREE: | HELPLINE: +971 44494067| EMAIL: contactus@lifecellinternational.com| www.lifecellinternational.com 800 54332355 LifeCell Arabia FZ LLC, Suite 2621, Shatha Tower, PO Box 502026, Dubai Media City, Dubai, UAE.
EFCA/INT/BC/Jan 12/V-001
Client Enrollment Form & Agreement Name: .......................................................................... CRM No.: ..................................................................... APP. No.: ...................................................................... Country :.......................................................................