WP E-Signature by Approve Me - Sign Documents Using WordPress -

ADSCC Cord Blood Consent Form

ADSCC License No: MF5527

Please select either one or both of the following:

I, (Mother’s full name), would like to consent for the below service/s:

Consent to store for future applications

Consent to donate and store for research purposes

Consent to both

Mother's Information
Mother’s Last Name:	First Name:	Emirates ID:
Contact Phone:	Email:	Mother’s DOB:
Address:	City:
Father's Information
Father’s Last Name:	First Name:	Emirates ID:
Contact Phone:	Email:	Father’s DOB:
Address:	City:

Mother's Information

Mother’s Last Name:

First Name:

Emirates ID:

Contact Phone:

Email:

Mother’s DOB:

Address:

City:

Father's Information

Father’s Last Name:

First Name:

Emirates ID:

Contact Phone:

Email:

Father’s DOB:

Address:

City:

I (name of mother), on behalf of myself and my unborn Child ("my Child") hereby grant permission to Abu Dhabi Stem Cell Center (ADSCC) to receive, process and test cord blood taken from the placenta and umbilical cord of my child following delivery and/or Cord Tissue. The Cord Blood and/or Cord Tissue will be processed, cryopreserved and privately stored for future medical application.

The decision to collect the Cord Blood, Cord Tissue and/ or placenta should be made by the medical team attending the birth. ADSCC will provide the Collection Kit for the Services I have chosen. Only Blood and Tissue procured using an appropriate ADSCC kit will be processed. The Collection Kit must only be used by a trained and licensed healthcare professional or phlebotomist.

I understand that there is no guarantee or assurance of the success of the collection procedure or that the Cord Blood and/or Cord Tissue or placenta will be suitable for processing by ADSCC. I understand that the collection procedure should cause me no discomfort or pain nor interfere with the birth. I understand that I should discuss with my medical team any concerns that I have about the collection procedure and any risks that it may present to my child or me.

I understand that my participation in the Cord Blood and/or Cord Tissue collection procedure is voluntary and that I may stop such collection at any time and withdraw my consent. Stopping collection will not affect my child or my treatment in any way.

I am aware that my treating physician is required to test a sample of my own blood to confirm the suitability of the Cord Blood and/ or Cord Tissue or placenta for storage. My primary physician will conduct PCR and serology testing on the primary maternal blood sample in accordance with the relevant regulations and guidelines applicable to human tissue and cell banks. I understand that such tests may reveal that I am suffering from a disease of which I was previously unaware.

I have completed the Mother’s Medical History and agree to provide ADSCC with any further, relevant information if my child later develops a disease that may affect the storage of the Cord Blood and/or Cord Tissue, placenta sample.

I understand that the effectiveness and success of using stem cells for specific therapeutic treatments depends on the circumstances of each individual case. Even if the Cord Blood Stem Cells and/or Cord Tissue, placenta is successfully stored and are capable of use in therapeutic treatments, the success of such treatments cannot be guaranteed.

I understand that the provision of services by ADSCC is subject to its Terms and Conditions which have been provided to me and to which I agree.

I have fully understood the information provided. I have had the opportunity to ask questions to my primary physician and have been provided with satisfactory answers. I confirm all the information I have provided is true to the best of my knowledge.

Occasionally, the processing of Cord Blood and/or Cord and placental Tissue can result in leftover material which is disposed of as clinical waste. In order for us to improve our processes and methodology, it may be useful for us to be able to use this leftover material for quality control, validation purposes, research and manufacturing or other purposes as we see fit. Do you agree to any excess material being used in this way?

Please tick "YES" or "NO"

YesNo

Please sign under each section to store (1) cord blood, or (2) cord tissue, or (3) placental tissue or all (1 to 3):

Cord Blood

Cord Tissue

Placental tissue

Mother’s Signature:

Husband’s Full name:

Husband’s signature:

Date:

Primary Physician full name:

Primary Physician Signature:

Witnessed by:

Name of Witness:

Employee I.D number:

Signature of witness:

Proceed to Informed Consent for Infectious Disease Testing, Information and Health History and Health Questionnaire.

Mother's Information
Mother’s Last Name:	First Name:	Emirates ID:
Contact Phone:	Email:	Mother’s DOB:
Address:	City:
Father's Information
Father’s Last Name:	First Name:	Emirates ID:
Contact Phone:	Email:	Father’s DOB:
Address:	City:

Mother's Information

Mother’s Last Name:

First Name:

Emirates ID:

Contact Phone:

Email:

Mother’s DOB:

Address:

City:

Father's Information

Father’s Last Name:

First Name:

Emirates ID:

Contact Phone:

Email:

Father’s DOB:

Address:

City:

PURPOSE

We are inviting you to donate your baby’s □umbilical cord (UC), □ cord blood and □ placenta for research purposes. This donation may bring potential benefits for scientific advancements, medical research and potentially life-saving treatments. You may check the box next to the tissue that you would like to donate.

ADSCC (Abu Dhabi Stem Cells Centre) investigators use the donated umbilical cord, cord blood and placenta in:

Medical and basic research to study the therapeutical potential of these tissues in disease treatment.
Regenerative medicine

No donor information will be provided to the researchers working with the tissue, they will not be able to identify you or your personal information. ADSCC Researchers conduct experimental studies using the donated tissue that has no way to be traced back to you. This research will not be limited to the types of studies listed above.

PROCEDURES

If you agree to donate the umbilical cord, cord blood and/or placenta for medical research, nothing additional is required from you. After the samples are collected, they will be tested to see if they meet all the quality requirements.

All research studies using umbilical cord, cord blood and placenta must first be approved by the ADSCC Ethics Committee and/or DOH Ethics Committee, as per current regulations on clinical research that uses human tissue.

If you have had any genetic or infectious disease that can be transmitted to your descendant, you can auto exclude from the UC and placenta donation and it will not implicate any change in the medical care you are receiving.

You consent that the entity responsible for the donation program in your location can transfer your data referring ad/or you and your descendant baby to the ADSCC so that we can be used to manage the donation process under the terms provided for in the applicable legislation.

You consent that the ADSCC Cord Blood Bank (CBB) or the entity responsible for the donation program in your location contact you to ask about your son’s or daughter’s health status after birth.

You understand that if your son or daughter develops a potentially communicable disease, you will notify the ADSCC CBB by calling 800 140.

You consent to give a blood sample to carry out the tests required on the day of delivery and to keep samples for possible new tests if the donation has been adequate. Furthermore, any pathological result detected in the analysis will be communicated to you by the responsible doctor.

POSSIBLE RISKS AND BENEFITS

There are no physical risks to you or your baby by donating the umbilical cord, cord blood or placenta to be used in medical research.

The donation will not benefit you or your baby directly. However, this donation has the potential to contribute to scientific advancements that may benefit individuals or society in the future. This research may help future patients who need medical treatment.

CONFIDENTIALITY

ADSCC follows all ADHICS regulations and upholds the highest standards of professionalism, integrity and privacy throughout the entire process and your donation process will not intentionally be disclosed to any unauthorized individuals or organizations. There is a very small risk that an unauthorized person could find out that you have donated tissue(s) to ADSCC, however, several procedures are in place to keep your data private. No identifiable information about you will be given to the researchers, nor will your identity be published or presented at scientific meetings.

REIMBURSEMENT AND COSTS

You will not be paid for donating your baby’s tissue(s) for medical research. It will not cost you anything to donate your baby’s umbilical cord, cord blood and/or placenta for medical research.

VOLUNTARY PARTICIPATION IN AND WITHDRAWAL

Your donation is entirely voluntary, and you have the right to withdraw the consent form at any time, without any adverse consequences or prejudice.

If you choose to no longer participate, the birth tissue(s) will be discarded as medical waste, unless they have been already used.

If you decide to donate your baby’s umbilical cord, cord blood and/or placenta for medical research you may change your mind at any time in the future. If you decide you don’t want your baby’s umbilical cord, cord blood and/or placenta used for medical research, the tissue will be removed from ADSCC storage and discarded as medical waste and destroyed if has not already been used. This will not affect your relationship with ADSCC.

ALTERNATIVE TO PARTICIPATION

You may choose not to donate your baby’s umbilical cord, cord blood and/or placenta for medical research. If you choose not to, your unit will be discarded as medical waste.

QUESTIONS OR CONCERNS

ADSCC contact 800 140.

SUBJECT’S STATEMENT OF CONSENT

I have read this consent form and I have been given the opportunity to ask questions. I voluntarily agree to donate my baby’s □umbilical cord, □ cord blood and/or □ placenta for medical research studies, defined in this consent form. Please check the box next to the tissue that you would like to donate.

Mother’s full name:

Mother’s Signature: Date:

Husband’s full name:

Husband’s Signature: Date:

Physician full name:

Physician signature: Date:

Interpreter/ Witness full name:

Interpreter/ Witness signature: Date:

Mother's Information
Mother’s Last Name:	First Name:	Emirates ID:
Contact Phone:	Email:	Mother’s DOB:
Address:	City:
Father's Information
Father’s Last Name:	First Name:	Emirates ID:
Contact Phone:	Email:	Father’s DOB:
Address:	City:

Mother's Information

Mother’s Last Name:

First Name:

Emirates ID:

Contact Phone:

Email:

Mother’s DOB:

Address:

City:

Father's Information

Father’s Last Name:

First Name:

Emirates ID:

Contact Phone:

Email:

Father’s DOB:

Address:

City:

Baby Information
BABY’S DUE DATE:	DELIVERY PHYSICIAN’S NAME:	PHONE:
CLINIC NAME:	DELIVERY HOSPITAL NAME:	PHONE:
HOSPITAL ADDRESS:	CITY:
BABY’S RACE AND ETHNICITY INFORMATION
Baby’s Race: Response is required. Of which group(s) is your baby a member? (Select all that apply.)
Alaska Native or Aleut (ALANAM)	African (AFB)	Chinese (NCHI)
North American Indian (AMIND)	African American (AAFA)	Filipino (Philipino) (FILI)
American Indian South or Central American (AMIND)	Black Caribbean (CARB)	Japanese (JAPI)
Caribbean Indian (AMIND)	Black South or Central American (SCAMB)	Korean (KORI)
	South Asian (SCSEAI)	Vietnamese (SCSEAI)
	Other Southeast Asian (SCSEAI)
Native Hawaiian or Other Pacific (OPI)	White
Guamanian (OPI)	Eastern European (CAU)	Northern European (CAU)
Hawaiian (HAWI)	Mediterranean (CAU)	Western European (CAU)
Samoan (OPI)	Middle Eastern (MENAFC)	White Caribbean (CAU)
Other Pacific Islander (OPI)	North Coast of Africa (MENAFC)	White South or Central American
	North American (CAU)	(CAU)
	Other White (CAU)

Please carefully review the following Health Questionnaire. If you require assistance in understanding any of the questions, please feel free to contact ADSCC.

It is mandatory to complete all the requested information on the health questionnaire before the collection of the umbilical cord and placenta. This is the only opportunity for ADSCC to gather this vital information from you. Failure to complete the questionnaire will result in disqualification. The questionnaire should be filled out privately by the expectant mother or in a private interview conducted by an approved screener. Your answers to these questions will be kept confidential.

If you are accepted into this program or if your baby's umbilical cord and placenta are collected, and you later discover a reason that would disqualify you from donating, please contact ADSCC. You will not face any penalties for withdrawing from the program at any time.

By signing below, I confirm that the information provided is true and accurate to the best of my knowledge.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

August 11, 2023 11:16 am +04

ADSCC Cord Blood Consent Form Uploaded by Cellsave Arabia - csait@cellsave.com IP 5.32.48.90

August 13, 2023 10:42 am +04

Call Center - cs-agents@cellsave.com added by Cellsave Arabia - csait@cellsave.com as a CC'd Recipient Ip: 94.204.26.150

August 13, 2023 10:42 am +04

Field Agents - fieldagents@cellsave.com added by Cellsave Arabia - csait@cellsave.com as a CC'd Recipient Ip: 94.204.26.150