PacifiCord Enrollment Form

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This is an agreement between Healthbanks Biotech USA, Inc., d.b.a. PacifiCord ("PacifiCord", or "We") and you, the expectant mother ("Client or You"). PacifiCord's services are designed to preserve the blood in your unborn child's ("the Child") umbilical cord and the placenta at the time of delivery ("cord blood"). PacifiCord Provides the Kit. PacifiCord will provide a cord blood collection kit to you to be used following your delivery. We will also provide you with information to provide to your medical professional who will be collecting the cord blood, whether that is a physician, midwife, or other person you authorize to do this for you ("Medical Professional"). Use of a Medical Professional. Your Medical Professional will collect the cord blood. You will choose your medical professional and pay for their services. Your Medical Professional shall not be construed to be an agent or employee of PacifiCord. Your Medical Professional is not the agent of PacifiCord and is in no way affiliated with PacifiCord or parent company. PacifiCord assumes no responsibility for assessing the qualifications of your hospital(s), physician(s), or other Medical Professionals. Notification upon Collection and Transport of Collected Cord Blood. You are responsible for following the shipping procedures and instructions included in the collection kit. You, your medical professional, family, or friend will need to contact PacifiCord as soon as possible once you are in labor or when the cord blood has been collected. PacifiCord employs its own courier who once notified, will pick up your cord blood and deliver it directly to our lab. Alternatively, you may use a courier of your choice. Should you do so, you understand that PacifiCord is not responsible for third party courier transport of your collection kit to PacifiCord's facilities. Client agrees that PacifiCord is not liable for loss destruction or deterioration of the cord blood prior to receipt at PacifiCord's facilities. PacifiCord will Test the Cord Blood and Your Blood. It will be important for PacifiCord to draw some blood from you, the Child's mother, in order to test it for traits that will help confirm whether your Child's blood is eligible for storage. You consent to these tests, or arranging for a third party to test your blood and the cord blood. Client agrees to give PacifiCord authorization to test maternal blood and/or blood samples and also agrees release of any abnormal test results to the client's primary care physician. The test will be for HIV, hepatitis and syphilis, as well as for other conditions required by government regulatory agencies, and/or otherwise related to the suitability of the cord blood for storage. You agree to permit PacifCord to collect and test your blood within 48 hours of delivery of your Child. Upon delivery to PacifiCord, we will also test the cord blood for the same reasons. Of course, we will provide you with notice of the results of these tests. PacifiCord will Preserve and Store the Cord Blood. If the cord blood is suitable for storage, we will process, cryopreserve and store the cord blood until such time that your Child needs it, or this agreement terminates, whichever comes first. Sometimes PacifiCord's Service is not Available. Your health, the health of your Child, and providing a service of value are of utmost importance to us at PacifiCord, and sometimes preserving these values mean that we cannot provide our services to you. For example, whether the cord blood can be safely collected at the time of delivery is entirely the decision of your Medical Professional. If it is not safe for you or your Child or for any other reason in the sole discretion of your Medical Professional, then the cord blood will not be collected. Further, if the cord blood is made unusable for reasons including, but not limited to, incorrect collection method, the collected cord blood is not returned to PacifiCord for preservation in time, there was not enough time to arrange for PacifiCord's services, wrong delivery place, less than 34 weeks gestation, the amount collected is too small, bacterial, and/or a viral or genetic reason the sample doesn't meet company standards, then PacifiCord would not be able to provide the level of service you are entitled to, so PacifiCord service would not be available. If for any reason PacifiCord is unable to continue to provide storage services, your sample will be transferred at no cost to you to another facility (as determined by PacifiCord) which is authorized under applicable law to receive and store cord blood. Rights to Cord Blood. If your Child needs the cord blood, we will release it to you or your Child's authorized physician. You control the rights to the cord blood until your Child's 18th birthday. When your Child reaches the age of 18, we will transfer the rights to the cord blood to him or her, and you agree to this. We will not change our storage price to you or your Child for the 18 years after signing this Agreement. Support for You. PacifiCord will provide you with customer support. Completion of Forms. It is very important that you agree to read and complete all of the forms in this package. We hope you understand that PacifiCord cannot provide our services to you until you do this, because we want you to be fully informed. Your Due Date. You will inform PacifiCord of your due date. It is important that we know this so that we can prepare to give you the best service. Please enroll as early as possible. Less than 5% of babies are born on their due dates. Collection of Cord Blood. It is essential that you arrange for collection of the cord blood with your Medical Professional, remember to bring your PacifiCord Collection Kit to where you are going to deliver, and to use the PacifiCord Collection Kit. Payment for Services and Termination. You agree to pay all of PacifiCord's fees for the services you request. If you fail to make a required payment, we will send you a written notice at the address you provide. If your Child is at least 18 years old, and is making the payments to PacifiCord, we will send a written notice to your Child at the address you or your Child provides. You may terminate this agreement for any reason upon sixty (60) days advance written notice and have the right to specify the disposition of your cord blood to a designated location or physician which is authorized under applicable law to receive cord blood. If sixty (60) days after notice for payment is sent, the account has not been fully paid, or in the event of your voluntary termination no instructions are received for disposition, PacifiCord has the right to dispose of the cord blood for value or otherwise, without notice to you. You will not be entitled to any refund or compensation and PacifiCord will retain all rights to the cord blood unit. What Happens When Your Child Needs the Cord Blood. Before your Child reaches the age of 18, you will have the right to request the use of the cord blood. When your Child reaches the age of 18, you will transfer the rights to the cord blood to him or her, and he or she will have the right to request the use of the cord blood. If your Child needs the cord blood, you agree to notify PacifiCord in writing a minimum of two weeks prior to prepare and ship the stored cord blood to a designated location or physician which is authorized under applicable law to receive cord blood. You will arrange for and be responsible for shipping and payment of all transport fees. Upon release of the cord blood to your designated courier, PacifiCord will be released of any and all liabilities including any loss, destruction or deterioration of the cord blood. If you request any future testing of the cord blood, or related tests, you or your Child agree to pay for it. PacifiCord will then release the cord blood to your shipper and/or cause the test(s) to be performed. Keep in Touch. You need to inform PacifiCord of any changes in circumstances would affect our ability to provide our service to you or your Child, such as a new address or telephone number. Client agrees to keep PacifiCord notified of current address and notify PacifiCord in writing of any changes in address throughout the term of this agreement. Confidentiality. PacifiCord agrees to use reasonable efforts seeking to maintain confidentiality or information provided by you or your Child. This provision shall be deemed not to restrict disclosure required by law, requested by any government agency or public authority, inadvertent disclosures due to unintentional release of information, disclosures resulting from media attention, disclosures made by individuals, whether or not employed by PacifiCord, disclosures of information resulting from computer hacking, or any other type of intruder acting without company authorization, release of information to your Medical Professional and any medical associations he or she may be affiliated with, such as the hospital where you will deliver, laboratory or anyone for the claimed purpose of providing health or medical services to you or your Child, or disclosures to professional consultants or advisors to PacifiCord, or disclosures as part of a potential or actual sale, transfer or assignment of any or all rights or obligations of PacifiCord under this Agreement. Shipping. In the event you/your Child need the cord blood in the future, you will need to arrange to have it picked up and delivered to your authorized physician. As part of your arrangements, you will be responsible for cost of shipment, and PacifiCord is not responsible, or liable, for this. No Warranty. YOU ACKNOWLEDGE THAT NEITHER PACIFICORD, ITS AFFILIATES, SUCCESSORS, ASSIGNEES, OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, INDEPENDENT CONTRACTORS or SUBCONTRACTORS HAVE MADE ANY REPRESENTATIONS, GUARANTEES OR WARRANTIES, EXPRESS OR IMPLIED, TO YOU OF ANY TYPE OR NATURE, INCLUDING WITHOUT LIMIT, THE GENERALITY OF THE FOREGOING, WARRANTIES OR GUARANTEES (except as stated in PacifiCord's Quality Product Guarantee, enclosed) WITH RESPECT TO 1) THE THERAPEUTIC, OR OTHER VALUE OF CORD BLOOD EITHER NOW OR IN THE FUTURE, 2) THAT YOUR CHILD MAY EVER NEED THE CORD BLOOD, 3) THE SUITABILITY OF THE CORD BLOOD FOR THE USE OF ANOTHER FAMILY MEMBER, 4) THE GUARANTEED SUCCESS OF COLLECTING THE CORD BLOOD, 5) THE SUITABILITY OF THE CORD BLOOD FOR STORAGE, 6) THE DETERIORATION, LOSS, DEGRADATION, OR SPOILAGE OF THE CORD BLOOD, 7) THE MERCHANTIBILITY OR FITNESS FOR A PARTICULAR PURPOSE OR USE OF ANY PRODUCT OR SERVICE HEREUNDER, 8) OR THAT PACIFICORD PERFORM'S MEDICAL SERVICES OR GIVES MEDICAL ADVICE. Release of PacifiCord & Hospital. You on behalf of yourself and your Child release PacifiCord, its affiliates, its shareholders, directors, officers, employees, agents, affiliates, insurers, professional advisors, service providers, successors and assignees from any and all liability for any and all loss, harm damage or claim of any kind related to the collection, handling, processing, storage, and maintenance of the cord blood or otherwise in connection with the Storage Services, except for PacifiCord's gross negligence or willful misconduct, as well as any damages whatsoever arising or resulting from the action of others, including your Medical Professional, the hospital staff, and the shipper who transports your Child's cord blood. Acknowledgement of Release. You on behalf of yourself and your Child acknowledge that by the releases in this Agreement you give up for you and your Child any right you or your Child may have now or in the future to sue or otherwise seek money damages or other relief against PacifiCord for any reason related to the collection, handling, processing, storage and maintenance of the cord blood. You on behalf of yourself and your Child acknowledge being aware of, or now learning, Section 1542 of the California Civil Code, which provides: A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him would have materially affected his settlement with the debtor. YOU ON BEHALF OF YOURSELF AND YOUR CHILD, WAIVE ALL RIGHTS UNDER SECTION 1542 OF THE CALIFORNIA CIVIL CODE OR SIMILAR LAWS IN ANY APPLICABLE JURISDICTION, FOR ANY CLAIM ARISING OUT OF OR RELATING TO A MATTER RELEASED HEREIN. Limit on Liability. PacifiCord does not guarantee against any possible loss, degradation, spoilage, contamination or the like of any portion or all of the cord blood for any reason, including without limitation, as a result of HealthBank's negligence or as a result of circumstances beyond PacifiCord's control such as, without limitation, war, fire, terrorist attacks, power outage, or natural disaster. PacifiCord and its related parties are responsible only for exercising ORDINARY CARE in connection with providing its services herein and will not be liable for any damages other than as described in this paragraph. You on behalf of yourself and your Child agree that if PacifiCord is found liable for gross negligence or willful misconduct, the amount of damages you may incur shall be limited to the amount of money paid by you and your heirs, successors and assignees pursuant to this Agreement. You understand and agree that PacifiCord is not responsible for, and assumes no direct, indirect, punitive, incidental, special, or consequential damages. PACIFICORD EXPRESSLY DISCLAIMS ANY EXPRESS OR IMPLIED WARRANTIES OF MERCHANTIBILITY OR FITNESS FOR A PARTICULAR PURPOSE. Indemnification. You on behalf of yourself and your Child agree to indemnify, defend and hold PacifiCord, the hospital, physicians, medical staff, your Medical Professional, and each of their respective shareholders, members, directors, officers, managers, employees, agents, affiliates, insurers, professional advisors, service providers, successors and assignees harmless from any and all claims, liabilities, demands and/or causes of action asserted by you or your Child or other person(s) for whose benefit the cord blood is being collected and stored. In no event shall PacifiCord have any obligation to indemnify you or your Child for any claims, damages, liabilities, costs or expenses arising or resulting, directly or indirectly, out of childbirth or PacifiCord's services to you. Waiver. This is our Agreement on how we will address any issues that arise between us, and as such, you agree to waive any other legal claims you may have against us that are outside the scope of what we agree to in this Agreement. Governing Law, Jurisdiction & Venue. In the event of a dispute arising from this Agreement or its interpretation, the laws of the State of California shall control. Jurisdiction and venue for any such dispute shall be in the Federal or State Courts located in Orange County, California. Attorneys' Fees and Costs. In the event of a dispute arising from this Agreement or its interpretation, the prevailing party to such action shall be entitled to collect its reasonable attorneys' fees and costs incurred in such action from the other party. Future Laws. In the event the government passes new laws or changes existing ones, you acknowledge PacifiCord's right to change or modify its procedures in order to comply with these new laws or changes to existing laws, and may pass on to, and/or require you to bear some or all of the costs associated with these changes. Arbitration. All disputes, which arise under this Agreement, shall be referred and resolved by a single arbitrator mutually acceptable to both parties. Arbitration shall be conducted in California. Sections 1280 to 1289 of the California Code of Civil Procedure shall govern. Your Representations and Warranties. In addition to the other representations and warranties you have made in this agreement, you represent and warrant that you are the parent of the Child, or the prospective legal guardian of the Child, thatyou were advised to obtain medical and legal advice prior to signing this agreement, and that your decision to enter this Agreement and abide by its terms was completely voluntary. In the event you do not become the legal guardian of the Child, this agreement will terminate, PacifiCord will have the right to dispose or use the cord blood as set forth herein, and your sole remedy will be a refund of amounts you paid to PacifiCord, less $ 150 which PacifiCord has a right to keep. Sole Agreement. This is the entire agreement between you and PacifiCord. Any prior representations, statements, negotiations, omissions or agreements that precede this Agreement are integrated into and superseded by this Agreement and are null and void. Modification. Subject to the paragraph above regarding future laws, this Agreement cannot be modified without the written consent of both parties. Assignment. PacifiCord may assign this Agreement to any individual, association, partnership or corporation that is either providing a similar service or intends subsequent to such assignment to provide a similar service, whether or not as part of a sale, transfer or assignment of all or part of PacifiCord's business, or for other reasons or in other circumstances, and PacifiCord shall require that this Agreement remain in full force and effect. Death or Disability. In the event of your or your Child's death or disability, PacifiCord shall be entitled to rely on the instructions of your or your Child's estate, guardian, conservator, trustee, administrator or the other similar responsible person or successor in interest. Data Collection and Study. You acknowledge and allow on behalf of yourself and your Child that PacifiCord shall have the right to aggregate data, provide aggregate data to others for any purpose, to use information obtained through services provided to you and/or your Child, for purposes of research, development, marketing, applying for patents, licensing and other development and use of intellectual property, or know-how, whether or not any of these activities are intended to or actually benefit or generate revenue or profit to PacifiCord. PacifiCord's only obligation to you and your Child is to use reasonable efforts to avoid disclosure of information that specifically identifies you or your Child. Notice. You may contact us at: 185 Technology Dr. Suite 150 Irvine, California 92618, telephone (888) 379-2673, facsimile (949) 789-0337. We will contact you at the address you provide in this enrollment package, and update. Force Majeure. If the performance of this Agreement, or any obligations arising under this Agreement, is prevented, restricted or interfered with by reason of fire, earthquake, flood, or other casualty or accident, strikes, labor disputes, war or other violence, any law, order, proclamation, ordinance, demand, or requirement of any government agency, or any other act or condition beyond the control of PacifiCord, PacifiCord shall not be liable to you or your Child. Method of Execution. This Agreement will be fully enforceable and binding upon PacifiCord's receipt by email or facsimile of your manual signature executing this Agreement and where required in its related documents. Upon receipt of these signatures, there is no need to send the original manually executed signature page(s). Digital signatures, electronic signatures, typed signatures, stamps, and other non-manual signatures are not accepted by PacifiCord. Survival. All covenants and agreements made in this Agreement, that, by their terms, require performance after termination of this Agreement, shall survive the termination of this Agreement. Severability. If any provision of this Agreement is held by a court of competent jurisdiction to be invalid, void or unenforceable, the remaining provisions shall nevertheless continue in full force and effect without being impaired or invalidated in any way. Binding. All of the obligations, terms, provisions, and releases set forth in this Agreement shall be binding upon and inure to the benefit of PacifiCord and you, as well as to each party's respective heirs, personal representatives, successors and assignees. (Informed Consent) Your Medical Professional Collects the Cord Blood . Your Medical Professional will collect the cord blood, and you agree to allow him, her or them, to do so. You will choose your medical professional and pay for their services. Your Medical Professional shall not be construed to be an agent or employee of PacifiCord. Your Medical Professional is not the agent of PacifiCord and is in no way affiliated with PacifiCord. PacifiCord assumes no responsibility for assessing the qualifications of your hospital(s), physician(s), or other Medical Professionals. Benefits & Risks. Recently science has been able to enable stem cells to grow into cells of a variety of different types of tissues. Doctors hope to someday be able to grow stem cells into the types of tissue or other cells needed by a patient. Currently, they believe that a person's own stem cells show the greatest potential to be used by that person (as opposed to using someone else's stem cells). As with any new, experimental procedure, there are risks but it is hoped that this technology will be able to be applied to many different medical uses where using the patient's own cells is a benefit, or requirement, in a medical treatment. There is currently no guarantee that these stem cell treatments will work, will be a match for any family member, that any treatments that do exist will apply to your child, or that your child will ever need it. Further, there is still the risk that using it could cause organ damage, failure to engraft, disease, complications, illness and even death. That is why it is important to talk to your doctor about this. Obviously, you are taking steps today that will hopefully be of benefit to your child in the future on the belief that treatments and science will develop beneficial uses for this cord blood. When PacifiCord's Services May Not be Available. Your health, the health of your child, and providing a service of value are of utmost importance to us at PacifiCord, and sometimes preserving these values mean that we cannot provide our services to you. For example, whether the cord blood can be safely collected at the time of delivery is entirely the decision of your Medical Professional. If it is not safe for you or your child, or for any other reason in the sole discretion of your Medical Professional, then the cord blood will not be collected. Further, if the cord blood is made unusable for reasons including, but not limited to, incorrect collection method, the collected cord blood is not returned to PacifiCord for preservation in time, there was not enough time to arrange for PacifiCord's services, wrong delivery place, less than 34 weeks of pregnancy, the amount collected is too small, bacterial, and/or a viral or genetic reason the sample doesn't meet company standards, then PacifiCord would not be able to provide the level of service you are entitled to, so PacifiCord's service would not be available. Your Blood and Your Child's Blood will be Tested . It will be important for PacifiCord to draw some blood from you, the Child's mother, in order to test it for traits that will help confirm whether your child's blood is eligible for storage. You understand that this may cause you some discomfort or pain, for example that discomfort or pain experienced when the needle is inserted to draw the blood, or the red mark that remains after the needle is removed. You consent to these tests, or arranging for a third party to test your blood and the cord blood. The tests will be for HIV, Hepatitis B and C, HTLV and syphilis, as well as for other conditions required by government regulatory agencies, and/or otherwise related to the suitability of the cord blood for storage. You agree to permit PacifiCord to collect and test your blood within 48 hours of delivery of your child. If the first test indicates that you carry one of these diseases, a second test will be performed for accuracy. If the test results of your blood sample are confirmed positive for HIV, the cord unit will not be stored. If your blood tests indicate the possible presence of any other infectious agent or the tests are inconclusive, the cord unit will be processed and cryopreserved only with the approval of PacifiCord's Medical Director. Of course, we will provide you with notice of the results of these tests. All blood samples may be stored for possible future testing. PacifiCord will provide a complete list of tests to be performed on your blood and the cord blood upon your request. Rights and Ownership of Cord Blood. All rights, title, interest and ownership of the cord blood belong to you, the Client until your Child reaches the age of 18, and you will have the right to request the use of the cord blood. When your Child reaches the age of 18, you will transfer the rights and ownership of the cord blood to him or her, and he or she will have the right to request the use of the cord blood. If your Child needs the cord blood, you agree to notify PacifiCord in writing a minimum of two weeks prior to prepare and ship the stored cord blood to a designated location or physician which is authorized under applicable law to receive cord blood. You will be responsible for payment of all transport fees. Upon release of the cord blood to you, PacifiCord will be released of any and all liabilities including any loss, destruction or deterioration of the cord blood. If you request any future testing of the cord blood, or related tests, you or your Child agree to pay for it. PacifiCord will then release the cord blood to you and/or cause the test(s) to be performed. You agree to pay all of PacifiCord's fees for the services you request. Upon termination of your agreement with PacifiCord (see Service Agreement), you have sixty (60) days to request release of your cord blood under the conditions previously described herein. If no request for release is received after sixty (60) days, PacifiCord will retain all rights to the cord blood unit and has the right to dispose of the cord blood for value or otherwise, without notice to you. Honestly Complete All Forms . You understand that you must read, understand, honestly complete and sign all of the forms included in this packet in order to receive PacifiCord's services. You acknowledge that: - You will complete a Medical Health Questionnaire as part of the enrollment process; - PacifiCord is permitted to draw a sample of your blood within 48 hours of delivery of your child and test it as noted above; - A review of your medical history and records may be required; - Your Medical Professional is permitted to collect the cord blood at birth; - The cord blood collection process does not pose a health risk to you or your child; - PacifiCord, or an outside lab, is permitted to test the cord blood as noted above, for infectious diseases; - That you enter into this Agreement voluntarily; - PacifiCord cannot perform its services without your full consent; and, - PacifiCord agrees to use reasonable efforts seeking to maintain confidentiality for information provided by you. This provision shall be deemed not to restrict disclosure required by law, requested by any government agency or public authority, inadvertent disclosures due to unintentional release of information, disclosures resulting from media attention, disclosures made by individuals, whether or not employed by PacifiCord, disclosures of information resulting from computer hacking, or any other type of intruder acting without company authorization, release of information to your Medical Professional and any medical associations he or she may be affiliated with, such as the hospital where you will deliver, laboratory or anyone for the claimed purpose of providing health or medical services to you or your child, or disclosures to professional consultants or advisors to PacifiCord, or disclosures as part of a potential or actual sale, transfer or assignment of any or all rights or obligations of PacifiCord under this Agreement. Ask Questions . If you have any questions, you can always contact PacifiCord or your physician.

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