ViaCord Customers

ViaCord Release Inquiry Form

Complete and submit the form below. Upon receipt, the ViaCord Clinical Affairs team will review your request. A team member will be in touch to confirm receipt and ask any follow-up questions, if necessary. They will let you know when the information will be sent to the treating facility or doctor.

If your doctor determines that stem cell therapy may be advantageous, we will work with your medical team to provide documentation and samples so that they can plan for treatment. We will also coordinate on the delivery of your child’s stem cell unit to the appropriate medical facility.

ViaCord Child ID This is the child ID associated with your Viacord account

Email * Email address that is associated with your ViaCord Account

Your Phone Number *

Name of Legal Guardian of Child This is most often the mother of the baby whose cord blood/cord tissue was collected from

Name of Recipient * Recipient is the person who would receive the cells as medical treatment

Recipient’s Relation to Donor* Please select from the drop down the recipient's relationship to the donor

Recipient’s diagnosis* What is the name of the medical condition to be treated with the cells

Name of Donor The Donor is the child from whom the cord blood/ cord tissue was collected

Donor’s Date of Birth Please provide donor's date of birth

Name of Doctor providing counsel or treatment Who is the doctor providing counsel or treatment

Name of Treating Facility/Hospital Where is the doctor providing counsel or treatment located

Treating Facility/Hospital listed above (City/State) Where is the doctor providing counsel or treatment

Name of contact person at Treating Facility/Hospital A person, other than the treating MD, who is managing the medical care- ie; Transplant coordinator, Case manager, Nurse

Contact Person's Email

Contact Person's Phone Number

Comments

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Disclaimer: Banking cord blood does not guarantee that treatment will work and only a doctor can determine when it can be used. Cord tissue stem cells have not been used in treatment yet. Research is ongoing. Genomic testing services are not for use in Diagnostic Procedures. The content shall not be used to make a diagnosis or to replace or overrule a health care provider’s judgement. Always consult with a qualified and licensed physician or other medical care provider.