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Required format:

MC3 Intake Form

Thank you for your interest in our cell therapy research program. For consideration for any of our current or future studies, including the Expanded Access Program, please answer the following questions regarding you/your child. Based on the information provided, additional instructions and/or information will be emailed to the address you submit.

Reminder: If you have already completed one of these entries for your child, please do not submit another one. If you are unsure of the next steps for your child, please email cordbloodtherapyinfo@duke.edu. Be sure to include your child's name and the name of the study for which they are being evaluated in all email communications.

DO NOT USE UNTIL POST-PRODUCTION STEPS HAVE BEEN COMPLETED

Please verify the patient demographic information on the Demographics Verification form.

Date/Time Created

M-D-Y H:M

Date Created

M-D-Y

Time Created

H:M

TESTING PURPOSES

Hide fields not necessary for testing

Show all fields in the survey

reset

Have you submitted a previous Cellular Therapy Inquiry survey response for this patient?

* must provide value

Is this child's umbilical cord blood stored in a public or family cord blood bank?

If you are 18 years of age or older, and wish to participate in one of our studies, is your umbilical cord blood stored in a cord blood bank?

* must provide value

Yes

reset

If yes, where?
UNHIDE

* must provide value

UNHIDE

Did you bank your child's cord tissue?

If you are 18 years of age or older, and wish to participate in one of our Brain Injury Studies, is your cord tissue stored in a bank?

Yes

reset

If yes, where?

* must provide value

Are any of your other children's umbilical cord blood stored in a public or family cord blood bank?

OR

If you are 18 years of age or older, and wish to participate in one of our studies, are any of your siblings' umbilical cord blood stored in a bank?

* must provide value

Yes

reset

If yes, where?

UNHIDE

* must provide value

Did you bank any of your other children's cord tissue?

OR

If you are 18 years of age or older, and wish to participate in one of our Brain Injury Studies, is your sibling's cord tissue stored?

* must provide value

Yes

reset

If yes, where?

* must provide value

Are your children full sibling?

OR

If you are 18 years of age or older, and wish to participate in one of our Brain Injury Studies, are your siblings full siblings?

UNHIDE

* must provide value

Yes

reset

Has your child been diagnosed with a genetic disease?

OR

If you are 18 years of age or older, and wish to participate in one of our Brain Injury Studies, have you been diagnosed with a genetic disease?

UNHIDE

* must provide value

Yes

reset

If yes, describe:

* must provide value

Has your child been diagnosed with HIV or Hepatitis B or C?

OR

If you are 18 years of age or older, and wish to participate in one of our Brain Injury Studies, have you been diagnosed with HIV or Hepatitis B or C?

UNHIDE

* must provide value

Yes

reset

Does your child need supplemental oxygen or a breathing machine to breathe?

UNHIDE

* must provide value

Yes

reset

Has your child ever received any other cell therapy?

OR

If you are 18 years of age or older, and wish to participate in one of our Brain Injury Studies, have you ever received any other cell therapy?

UNHIDE

* must provide value

Yes

reset

Other cell therapy

* must provide value

Has your child ever been diagnosed with cancer or a problem with their immune system?

OR

If you are 18 years of age or older, and wish to participate in one of our Brain Injury Studies, have you ever been diagnosed with cancer, or a problem with your immune system?

UNHIDE

* must provide value

Yes

reset

What diagnosis or problem?

* must provide value

Expand

Has your child ever been diagnosed with G6PD deficiency?

OR

If you are 18 years of age or older, and wish to participate in one of our Brain Injury Studies, have you ever been diagnosed with G6PD deficiency?

UNHIDE

* must provide value

Yes

reset

Please describe

* must provide value

Expand

First Name

UNHIDE

* must provide value

Middle Name

UNHIDE

Last Name (surname)

UNHIDE

* must provide value

Date of Birth

* must provide value

M-D-Y

Date of birth - Do not enter a future date

Current Age
	Year(s)


	Month(s)

Has your child been diagnosed with any of the following conditions (check all that apply):

* must provide value

Autism (ASD, Autism Spectrum Disorder, Aspergers)

Apraxia

Cerebral Palsy

Hydrocephalus/Cerebral Ventriculomegaly

Hypoxic brain injury (ie. HIE, near drowning)

Periventricular leukomalacia (PVL)

Pervasive Developmental Disorder (PDD)

Stroke

Other

ASD only

or (Other dx and NO CB)

Dispo - Not Eligible Email

Alert #100

CP, HIE, PVL, Stroke

Age 18-68 month

Potentially Eligible for CP?

Alert #101

HCP or

CP, HIE, PVL, Stroke

Age out of range (not 18-68 mo)

CB available = No

GMCFS/Motor Ability?

Alert #102

Other Dx or

HCP or

CP, HIE, PVL, Stroke

Age out of range (not 18-68 mo)

CB available = Yes

Alert #102

CP, HIE, PVL, Stroke

Age out of range (not 18-68 mo)

CB available = No

Alert #103

Other diagnosis

* must provide value

Patient's weight (in pounds)

UNHIDE

* must provide value

Date Weight Obtained

UNHIDE

* must provide value

M-D-Y

Gender

UNHIDE

Race

UNHIDE

* must provide value

Ethnicity

UNHIDE

* must provide value

Insurance

UNHIDE

Relationship

UNHIDE

* must provide value

First Name

UNHIDE

* must provide value

Last Name

UNHIDE

* must provide value

Date of Birth

UNHIDE

* must provide value

M-D-Y

Primary Email Address

* must provide value

Confirm Email Address

* must provide value

Confirm Email Address

Email addresses do not match. Please correct.

Phone

UNHIDE

* must provide value

Phone 2

UNHIDE

Optional
If Participant is 18 years of age or older
Phone

UNHIDE

Optional
If Participant is 18 years of age or older
Email Address

UNHIDE

Street Address

UNHIDE

* must provide value

City

* must provide value

State field will appear after Country is selected.

Country

* must provide value

State

* must provide value

State/Province

* must provide value

Zip Code

* must provide value

Add Another Contact?

Yes

reset

Contact 2

Parent, Legal Authorized Representative or Emergency Contact

First Name

Last Name

Relationship

Date of Birth

M-D-Y

Phone

Phone 2

Email Address

Same Address?

Yes

reset

Street Address

City

State field will appear after Country is selected.

Country

State

State/Province

Zip Code

Patient First Name	______
Patient Last Name (surname)	______
Patient Date of Birth	______
Patient Diagnosis	______
	______
Primary Email Address	______

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