Stem cell forms

The majority of these forms are PDFs and require Adobe Acrobat Reader 

Collection, testing and storage

  • 5110: Therapeutic Apheresis Services request for collection of stem cells, lymphocytes or white cells (if you use Internet Explorer highlight the link, right click and select 'Save target as' to download)
  • 5071:  request to collect and process stem cell and immunotherapy products (if you use Internet Explorer highlight the link, right click and select 'Save target as' to download)
  • INF1243: referral of patients for stem cell collection and processing
  • 2B: consent for the testing, storage and discard of stem cells or lymphocytes
  • 2K: guidance for healthcare professionals in consenting for the testing, storage and discard of stem cells or lymphocytes 

 

Cord blood collection 

  • 2C: request for directed collection
  • 2D: consent for directed collection, testing and cryopreservation
  • 2L: guidance for healthcare professionals in consenting for the collection, testing and cryopreservation for directed transplantation
  • 2R: information for mothers regarding directed cord blood collection 

 

Issue of cryopreserved products

  • 2F: request for issue of products
  • 2G: engraftment report: 30 days post stem cell transplantation
  • 2H: clinical outcome report: 100 days post donor lymphocyte infusion

 

Transfer and returns 

  • 2M: record of transfer of products between institutions 
  • 2N: stem cell product return

 

Request for discard

  • 1960: request for authorisation to discard a HPC or other cellular therapy product (if you use Internet Explorer highlight the link, right click and select 'Save target as' to download)