CBA Florida Inc. (fka CBAI)

[MrLong]

Hello dianebRN, donor forms relinguish control of property and consent is needed.

Consent for Placenta Donation
Name:


Address:
(City/State/Zip Code)

Phone Number:

The donated placenta is collected after the birth of the child and after the umbilical cord is cut. The agency collecting the placenta will pay for costs associated with the collection. The donated placenta is shipped to be prepared for transplant by a for-profit organization, Osiris Therapeutics, Inc, Columbia, MD. The placenta is prepared in such a way that transplants are available in the size and shape needed by the recipient of the transplant. Therapeutic uses of placenta transplants include wound repair, burn dressings and repair of other skin damage. While priority is given to domestic use, tissues may be transplanted outside of the United States. Research use of tissue unable to be transplanted includes developing forms and uses of tissues for new therapeutic uses. Tissues shall not be developed or marketed for cosmetic uses.

In knowing this information do you give consent to for the donation of the placenta for the purpose of transplantation and/or research?
Yes / No
In order to determine medical eligibility of the placenta, do you grant permission for all of the following:

· Attending physician or healthcare provider to collect or direct the collection of the placenta after delivery. Understands that the physician will decide in his or her sole judgment if and when the actual collection will take place. Mother will not hold the attending physician or other healthcare provider, any hospital staff, the hospital or birthing center itself or its affiliates, board members or other representatives responsible or liable for any act or omission regarding the handling or collection of the placenta Yes / No
· The Mother consents to providing one or more maternal blood sample(s) at the time of delivery of the child and to have them tested for certain infectious diseases (including, for example, Hepatitis B, Hepatitis C, Human T-Cell Lymphotrophic Virus (HTLV), Cytomegalovirus (CMV), Syphilis, and Human Immunodeficiency Virus (HIV). In the event of a positive test result, the Mother authorizes Cord Blood America, Inc. to provide such results to her physician, as well as to governmental agencies as required by law Yes / No
· Release of current and past medical records to all organizations responsible for determining the safety and acceptability of the transplant Yes / No
· Completion of a medical and behavioral risk assessment interview Yes / No

Do you understand the donation process as it has been explained to you and have you been provided the opportunity to ask questions, and if any, have you received satisfactory answers?
Yes / No























Donor Signature and Date:


Requestor Signature and Date: