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SmartBank is the umbilical cord stem cell bank for Your family since 2005

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Request service
 
(* must be filled)
*Mother’s first name:
*Mother’s surname:
Mother’s date of birth (dd/mm/yyyy)

Mother’s place of birth:

Fiscal Code where any:
Father’s first name:
Father’s surname:
Father’s date of birth (dd/mm/yyyy)
* Due date (dd/mm/yyyy)
Multiple birth:
*Address:
Postal Code:
*City:
Province:
*Telephone (or cell phone): 
Cell phone:
* E-Mail:
Clinic/Hospital to be used:
Doctor:
* How did you learn about us:
Are you interested in making the sample available for a possible donation?

Please write any requests or comments in the field below:

Kit to be Delivered to (only if different to the address provided):

The total cost is Euro 2,250.00 including VAT, (Euro 2000 for the service and Euro 250 for the Kit)

Payment must be made by bank credit transfer to SmartBank s.r.l’s current bank account, using the following bank account details:

Banca Popolare di Sondrio – Agenzia 8 di Roma
c/c 4914x09 – SMARTBANK s.r.l.
ABI (bank code): 05696 – CAB (branch code): 03208 – CIN: E
IBAN: IT 46 E 05696 03208 000004914x09

The undersigned, having understood the information provided by the data controller pursuant to article 13 of the legislative decree n. 196/2003, and in particular aware that handling of data will concern "sensitive data" as set out in article 4, paragraph 1 letter d), and also article 26 of the legislative decree 196/2003, i.e. data “suitable for revealing racial and ethnic origin, religious, philosophical or other beliefs, political opinions, membership of parties, trade unions, associations or organisations of a religious, philosophical, political or trade union nature, and also personal data suitable for revealing the subject’s state of health and sex life":

* I give consent for the handling of the data needed to carry out the operations stated in the information sheet. (read policy)

* I give consent for the communication of data to the subjects indicated in the information sheet

* I undertake to pay the amount of Euro 250.00 including VAT for the cryogenic storage kit.

"The consensus is essential for service delivery"
mod. 05.01 Ed. 1.1

2010©  SmartBank™ s.r.l.
Via Alessandro Torlonia, 16
00161 Rome (Italy)
Partita Iva: 08740021004