National Cord Blood Program

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SEARCH REQUEST

PATIENT REGISTRATION

Date: Sep 08 2010

* Patient's Last Name/Family Name:

* First Name:

* Birthdate:

* Ethnicity/Race:

* Gender: Male Female

* Diagnosis:

* Date of Diagnosis:

Stage:

* BodyWeight (kg)

Patient's HLA TYPING:

Please fax original HLA LAB REPORT for Class I and Class II High Resolution to fax number (212) 570-9061.

Serology	Allele
* A:
* B:
* DR:
	Please type 'bl' when field is blank.

HLA Laboratory: Date of Test:

NOTE: if a potential match is found, confirmatory HLA typing of patient will be required. NYBC's National Cord Blood Program will do confirmatory typing for no charge.

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