Maternal Health Pre Registration - Cord For Life

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Cord Blood Donation Registration

Thanks for considering saving your child’s cord blood and joining the group of mothers who are helping to build the nationwide inventory for people in need of a transplant.

About You
Name*
First Last
Email*
Phone*
Due Date
Date Format: MM slash DD slash YYYY
What Are Your Cord Blood Banking Plans?*
- Donate
- Privately Bank
Are you 18 or older?*
- Yes
- No
Are you and the baby's father related by blood (e.g. first cousins)?*
- Yes
- No
Are you expecting only one baby?*
- Yes
- No
Does your baby have any known fetal abnormalities?*
- Yes
- No
Tattoos and Piercings
In the last 12 months, have you had any tattoos or ear, skin, or body piercings where shared or non-sterile inks, needles, instruments, or procedures were used?*
- Yes
- No
Blood Diseases and Transfusions
Have you ever been told that you have aplastic anemia, hereditary spherocytosis, hereditary elliptocytosis, hypogammaglobulinemia, or polychythemia?*
- Yes
- No
In the last 12 months, have you needed red bloods cell or transfusion support?*
- Yes
- No
Infectious Diseases
Have you ever been exposed to or infected with hepatitis B or C, HIV or the AIDS Virus, West Nile, or Tuberculosis?*
- Yes
- No
Have you used a needle, even once, to take a drug not prescribed by a physician (including steroids) or in the last 12 months had sex with someone who has?*
- Yes
- No
Sexually Transmitted Diseases
In the last 12 months, have you been treated for syphilis or had a positive test?*
- Yes
- No
Have you, the baby's father, or any of the baby's siblings have ever had any type of cancer or leukemia (including skin cancers)?*
- Yes
- No
Malaria
In the past 3 years, have you had malaria?*
- Yes
- No
Medications
Have you been in contact with anyone who received the smallpox vaccine during your pregnancy?*
- Yes
- No
Have you ever been treated with chemotherapy?*
- Yes
- No
Have you ever taken any remicade, interferon, infliximab, etanercept, methotrexate, 6-mercaptopurine, imuran, cellcept, cyslosporine, or tacrolimus?*
- Yes
- No

Our purpose is to provide the expectant mothers with information necessary to discover the lifesaving potential of umbilical cord blood.

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