AMENDED STORAGE AGREEMENT

Please ensure the payment information below is filled out completely.

Personal Information
Mothers Name (Last, First, Middle):
Home Address:
City:

State:

Home Phone:

Email:

Zip:

Fathers Name (Last, First, Middle):

Other Contact Phone:

Email:
Next of Kin, Other than mother or father

Name (Last, First, Middle):

Relationship:

Address:
City:

State:

Home Phone:

Email:

Zip:

STORAGE OPTIONS: I am an existing client of NECBB through ______________________ and I hereby authorize the
Company to convert my existing storage to the new long term storage as indicated below. I also acknowledge that by selecting a new
Storage Plan, the storage of the Cord Blood will automatically renew annually (annual payment) at the end of the plan selected (5 or 10
or 20 years). For this reason I must maintain all my personal information up to date with NECBB.
CORD BLOOD NUMBER: _____________
CURRENT STORAGE

ADMIN NUMBER: ______________

NEW LONG STORAGE

Annual

Annual

N/A Empty Space

5 Year

N/A Empty Space

10 Year

N/A Empty Space

20 Year

The new storage option will become effective as of

Client Signature

Date

Office Manager Signature

Date

Copyright 2013 New England Cord Blood Bank, Inc.

Page 1 of 1

Rev. 03/2013