Cell Banking Agreement Refusal

Banking Stem Cells can provide treatment options including:

Current uses of stem cells include arthritis, and soft tissue injuries (tendon and ligament).
Future uses of stem cells may include treatment of kidney, inflammatory bowel disease, gingivostomatitis, and immune mediated diseases.

One fat collection can provide a lifetime of stem cell therapy by utilizing stored doses and/or cell culturing. Culturing of stem cells and processing of stored doses will incur costs. Consult your veterinarian for estimates of potential future costs for treatment.

Cell Banking Refusal^*

No - I do not wish to bank cells for my animal. I agree to donate and thereby relinquish all rights to, and associated with, my Animal's remaining stored cells. I authorize VetStem to use the remaining stored cells from my Animal for training and ongoing development of the technology.

No - I do not wish to bank cells for my animal. Please Dispose of all cells

Contact Information (please complete so that we have current information)

Animal Name^*

Species^*

Owner First Name^*

Owner Last Name^*

Owner Address^*

City^*

State^*

Country

Zip or Postal Code^*

Phone Number

Cell Phone Number

Email Address^*

Questions or Comments