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Health History Questionnaire



All information herein will be kept strictly confidential, save for declaration required by law and/or for transplant purposes. We request your kind understanding that sensitive questions are asked to help us make the cord blood collection process and subsequent use safe.


All "Yes" answers require an explanation. Please use the textbox allocated at the end of each question.

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12. In the past 5 years, have you:

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Travel History
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Genetic/ Family History
Has your baby’s biological father, his family members or any of your family members (biological parents and siblings) had:
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*The informed consent below applies to all Cordlife’s banking services you have enrolled for this pregnancy. The maternal blood test results and Medical Director’s decision may be required to determine eligibility of storage.

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I understand that appropriate confidentiality will be maintained for all patient records concerning the Service, but that the Department of Health, or other government agencies may inspect records in accordance with applicable laws or regulations. I therefore certify that I have answered the above questions truthfully and to the best of my knowledge.
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Minimum amount to pay is HK$5,000
Cordlife Storage Payment - 0.00 HKD
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ABOUT CORDLIFE
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Contact Us

Hong Kong Main Office & Laboratory:
Unit G15, G/F.,
Biotech Centre 2 No. 11 Science Park West Avenue
Shatin New Territories,
Hong Kong

Hotline: (852) 3980 2888
Email: info@hk.cordlife.com
Fax: (852) 25118882
Cord Blood/Umblical Cord Collection Hotline: (852) 3980 2888

Macau
Block 21-F,
No.43-53A Avenida do Infante D. Henrique,
Macau
Hotline: (853) 6881 0781
Email info@hk.cordlife.com
Fax (853) 2878 6717

Privacy Notice

Cordlife (Hong Kong) Limited is a subsidiary of Cordlife Group Limited, a Singapore Exchange (“SGX”) Main Board listed company, providing the service of cord blood and cord lining banking.
Copyright © Cordlife. All rights reserved.