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Thank you for your interest in stem cell banking with Celltex therapeutics.

Please complete the form below to enroll in stem cell banking or request to be contacted by a Celltex representative

Thank you for choosing to bank your stem cells with Celltex Theraputics.

Please complete the below enrollment form and proceed to payment.

Blood test screenings for HIV, Hepatitis B, Hepatitis C, and Syphilis are included in the cost of stem cell banking and are required prior to your fat extraction procedure. Positive tests results may affect your eligibility to bank your stem cells.

AGREEMENT FOR BANKING AUTOLOGOUS MESENCHYMAL STEM CELLS AND FOR PREPARING CELL PRODUCTS

I, , the "Client," requests CELLTEX Therapeutics Corporation ("CELLTEX") isolate, prepare, cryopreserve ("bank"), and, if requested in accordance with applicable law, expand and transport ("prepare cell products") my autologous mesenchymal stem cells ("stem cells") that I provide to CELLTEX in fat tissue. I agree to the following terms for Banking and Preparation of Cell Products.

  1. BANKING:
    1. Agreement to Blood Analysis: I understand that the first step of the stem cell banking process is that I will have laboratory tests. I understand that my physician will require my informed consent for the blood draw and for the release of blood analysis information to CELLTEX. I understand that my physician or CELLTEX may elect not to proceed with stem cell banking or preparation in the event that there is, in either my physician’s or CELLTEX’s opinion, any reason not to proceed on the basis of results of my blood analysis or health condition. I understand that blood analyses may result in false positive or false negative results for any of the items for which my blood is being evaluated. I understand that the blood analysis will consist of three separate components:
      1. Communicable Disease Blood Screening: My blood will be evaluated to determine the presence of or the antibodies to certain communicable diseases, including, but not limited to HIV, Hepatitis B, Hepatitis C, and syphilis. I understand that my physician will explain the findings and any reporting requirement should any of these tests be positive.
      2. Human Leukocyte Antigen Type: My blood will be evaluated to provide a human leukocyte antigen type (HLA) to be used by CELLTEX in its evaluation of my cells at CELLTEX as part of quality assurance.
      3. Comprehensive Blood Analysis: My blood will undergo a comprehensive blood analysis that may assist my physician in making a decision with me about whether I am healthy enough to undergo cell extraction. CELLTEX will, at my physician’s order, also evaluate the comprehensive profile and retain it for quality assurance and any subsequent use I may approve.
    2. Fat Tissue Collection: I understand I must give informed consent for this fat tissue collection procedure directly to the physician who will perform the procedure. The fat tissue collection procedure will be performed by a physician with whom Celltex has made prior arrangements for the packaging and shipping.
    3. Transportation of Fat Tissue Sample: Following the fat tissue collection procedure, my fat tissue will be transported to CELLTEX. I understand that some risks associated with transport of human cells are beyond the control of CELLTEX. Costs associated with any need to obtain another sample due to loss, damage, or destruction in transport by any carrier other than a CELLTEX courier are my sole responsibility.
    4. Extraction, Preparation, and Cryopreservation Process: I understand that once CELLTEX receives my fat tissue, it will isolate and extract the natural stem cells in my fat tissue. My stem cells will then be allowed to multiply in a culture medium at the cells’ natural growth rate until a sufficient number of stem cells have been identified. At that point, my stem cells will be cooled to the appropriate cryopreservation temperature and cryopreserved or will be prepared for transfer to my physician.

      DISCLAIMER OF WARRANTY
      I understand that CELLTEX cannot and does not warrant or guarantee that any stem cells will be extracted from my fat tissue, that my stems cells will multiply, or that any stem cells extracted from my fat tissue will be fit or usable for any purpose. I understand that no cells will be released to a physician unless my cells have multiplied in accordance with CELLTEX’s quality assurance standards.
    5. Cryopreservation: I understand that the process of cryopreservation involves cooling my stem cells to a very low temperature. I understand that this process reduces the metabolic activity of stem cells to a point that they may be stored for long periods of time. I understand that cryopreservation for very long periods (years) may have an effect on the viability of the cells.
    6. Release of Banked Cells to a Third Party: I may request my banked cells be transported to a party other than Celltex. Celltex shall comply with my request so long as it is not contrary to applicable laws including good laboratory practice standards. I agree I assume all responsibility for those vials at the time they leave Celltex’s custody and waive all claims against Celltex for those cells.
  2. PREPARATION OF CELL PRODUCTS:
    1. Cells Products Only by Physician Orders: I understand my stem cells may be prepared as cell therapy products at Celltex’s discretion only under orders from a physician licensed to practice medicine in the applicable jurisdiction and trained in the administration of autologous mesenchymal stem cells. I understand that the release of my cells is subject to applicable federal and state laws governing the banking, processing and related uses of stem cells and the conduct of physicians in the sovereign nations where those actions take place. I understand that Celltex will not create my cell product under any other circumstances.
    2. Transport: When ordered pursuant to paragraph II.A and paid in advance, Celltex shall prepare my cell product. I understand that only cells that meet Celltex’ s quality assurance standards will be released. Once released, my cells will be transported in a specialized container. I understand that there is a risk that my stem cells will be lost, damaged, or destroyed during the transportation process as a result of action or inaction by the carrier, acts of God, or undetectable defects in the container. I further understand that if shipped across a border there is a risk that my stem cells will not be permitted to enter the importing country because of applicable customs laws or the discretion of legal authorities. CELLTEX shall bear no responsibility for my cell product upon providing my stem cells to an appropriate courier or delivery service (such as Fed Ex) nor for my physician’s handling of my cells in his or her practice of medicine upon receipt of my cell product.
  3. FEES: I understand that the fees for Banking are set forth in the Celltex Stem Cell Banking Enrollment Form (2 pages) and for Cell Products are in the Celltex Cell Allowance Payment Form. Those documents are incorporated herein by reference. I understand that all applicable fees must be paid in advance to Celltex and are non-refundable under the terms stated in those attachments.
  4. DESTRUCTION OF AUTOLOGOUS MESENCHYMAL STEM CELLS: I understand that if, at any point, I wish to have any or all of my stored stem cells destroyed, I will be required to provide a signed, notarized, completed Celltex Destruction Request Form to CELLTEX. I understand that Celltex will then totally destroy my cells in their facility in accordance with the regulations governing laboratories in the State of Texas and best practices.
  5. DUTIES OF CARE: I understand that CELLTEX is not a provider of medical care. I understand that my physician(s) involved in the above processes shall provide any medical assessments, treatments, and all care required in testing, extraction, and ordering any use of my cells. WHILE I MAY ENGAGE IN EXTENSIVE CONVERSATION WITH EMPLOYEES OR OTHER DESIGNEES OF CELLTEX REGARDING ANY QUESTIONS I HAVE CONCERNING THE BANKING OF MY CELLS, I UNDERSTAND THAT CELLTEX DOES NOT PROVIDE CLINICAL CONSULTATION SERVICES OR ADVICE, NOR MAKE REPRESENTATIONS REGARDING MY MEDICAL CONDITION, TREATMENT MODALITIES, OR CHANCES OF SUCCESS OF ANY TREATMENT OF ANY KIND THAT MY PHYSICIAN MAY ELECT TO PROVIDE, NOR THE LIKELIHOOD OF POSITIVE EFFECTS THAT MIGHT OCCUR FOR ANY INTENDED USE OR IN ANY CLINICAL STUDY. Initial
  6. NATURE OF USE: I understand that CELLTEX has made no and makes no claims about the ability of stem cells to treat, cure, or have any effect upon my health or any clinical condition. Further, I understand that CELLTEX may decline to release my stem cells if a proposed use does not fall within good clinical practice, good laboratory practice and/ or applicable laws. I understand and agree that CELLTEX does not warrant or guaranty, and that CELLTEX is not responsible for, the actions of physician( s) and health care provider( s), or any products or services provided by any person or entity other than CELLTEX. Initial
  7. GENERAL RISKS: I understand that: (a) there are inherent risks in Banking and/or preparing my stem cells as a cell product, including but not limited to, loss, contamination, damage, or destruction of my stem cells, reduced viability of my stem cells after thawing, reduced capacity of unsuitability for subsequent use, and compromised or altered health from the infusion, injection, or other use of my stem cells; (b) any or all of my stem cells may be lost, damaged, or destroyed due to factors beyond the control of CELLTEX, including, but not limited to, fire, theft, vandalism, natural disasters, or acts of God, war, or terrorism and (c) a law or regulatory agency with applicable authority may prohibit my intended use of my stem cells. I understand and agree to assume responsibility for all of the above potential risks. Initial
  8. GENERAL RELEASE: Recognizing the risks discussed above, I, for myself and for my heirs, spouse, executors, administrators, agents, representatives, directors, officers, contractors, employees, successors, and assigns, hereby release CELLTEX and its employees, contractors, agents, officers, directors, subsidiaries, affiliates, successors, and assigns (collectively, "CELLTEX and Affiliates") from, waive, and intend this general release to be effective as a full and final accord and satisfaction of and as a bar to all actions, suits, demands, and claims of any type against CELLTEX and Affiliates relating, directly or indirectly, to my stem cells, the collection, extraction, growth, preparation, multiplication, expansion, cooling, cryopreserving, thawing, labeling, loss, damage, or destruction of any or all of my stem cells, loss, damage, or destruction of any sort to my stem cells in the transportation of my stem cells from CELLTEX, or any subsequent use of or inability to use my stem cells following cryopreservation. This general release shall extend to and cover any actions, suits, demands, and claims of any type based on any alleged action, inaction, representation, or omission of CELLTEX and Affiliates, whether known or suspected at the time of the execution of this Agreement, or which becomes known to or suspected by me at any time in the future. Initial
  9. DISCLAIMER OF WARRANTIES: Whether or not your stem cells are suitable, appropriate, useful, efficacious, or safe for use by you given your overall medical condition is something which only you and your physician can determine. CELLTEX does not provide medical services or advice and therefore cannot and does not make any representations or warranties to you or to your physician regarding the suitability, efficacy or safety of your stem cells. Your expanded stem cells will be delivered to you or to your physician pursuant to the terms of this agreement "as is". CELLTEX EXPRESSLY DISCLAIMS ALL REPRESENTATIONS AND WARRANTIES, WHETHER EXPRESS OR IMPLIED, OF ANY DESCRIPTION, INCLUDING ANY IMPLIED OR EXPRESS WARRANTY OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. Initial
  10. POSSIBLE USE OF YOUR CELLS BY CELLTEX: CELLTEX may elect to make use of some of your stem cells for research and development and for other purposes so long as the expansion of some of your cells for use by CELLTEX does not limit or interfere with the expansion of your cells for your own use. All expenses which may be associated with any use of your cells by CELLTEX, other than storage of your cells and the processing and transportation of your cells for delivery to you or to your physician for your use, are the responsibility of CELLTEX and CELLTEX may use your cells only on an anonymous basis and will not expressly identify you by name as the donor of the cells. Cells which are processed and used by CELLTEX at its expense shall become the property of CELLTEX. Initial
  11. LIQUIDATED DAMAGES: I specifically acknowledge and agree that in the event of loss, damage, or destruction of any or all of my stem cells by any reason whatsoever, legally recognizable damages of any sort to me or any other individual making a claim would be highly conjectural, speculative, and difficult to determine. Accordingly, I agree that in the event that any or all of my stem cells are lost, damaged, or destroyed by virtue of the breach of this Agreement or negligence by CELLTEX or its employees, contractors, agents, officers, directors, subsidiaries, affiliates, staff members, successors, or assigns, I, or any other individual making a claim shall be restricted to liquidated damages in the amount equal to the fees actually paid by me to CELLTEX. I AGREE THAT IN NO EVENT SHALL CELLTEX BE LIABLE FOR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, SPECIAL, EXEMPLARY, OR PUNITIVE DAMAGES, EVEN IF CELLTEX HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES, WHETHER ARISING UNDER ANY CONTRACT, NEGLIGENCE, STRICT LIABILITY OR OTHER THEORY, AND ARISING OUT OF OR RELATING IN ANY WAY TO THIS AGREEMENT OR ITS IMPLEMENTATION, INCLUDING BUT NOT LIMITED TO, FROM THE USE OF OR INABILITY TO USE ANY OF MY STEM CELLS. I ALSO AGREE THAT IN NO EVENT SHALL THE TOTAL LIABILITY OF CELLTEX ARISING OUT OF OR RELATING IN ANY WAY TO THIS AGREEMENT OR ITS IMPLEMENTATION EXCEED THE TOTAL AMOUNTS THAT I HAVE PAID TO CELLTEX. I AGREE THAT THIS SHALL CONSTITUTE MY DECLARATION OF VALUE OF THE STEM CELLS CRYOPRESERVED WITH CELLTEX, AND THAT THESE LIMITATIONS SHALL APPLY NOTWITHSTANDING THE FAILURE OF THE ESSENTIAL PURPOSE OF ANY LIMITED REMEDY.
  12. TERM: Unless earlier terminated for cause, the term ("Term") of this Agreement shall be for the period commencing on the date that this Agreement is signed by the client and ending upon the earlier of (a) the date on which all of the client’s cryopreserved stem cells have been supplied under II.A in this agreement so that none of my stem cells remain in Celltex’s possession, (b) Celltex’s destruction of the client’s stem cells in accordance with Destruction term IV of this agreement; (c) the expiration of the most recent term of Client’s non-lifetime banking agreement with Celltex (if any), (d) the expiration of Client’s lifetime banking agreement with Celltex (if any), and (e) my failure to pay my annual banking fee, if I fail to pay it within 30 days of a notice of my failure to pay it. I understand that after six months from the end of the Term of this Agreement, CELLTEX may promptly destroy my stem cells in its possession using any reasonable method.
  13. NOTICES: All notices under this Agreement by any Party to the other shall be in writing. All notices, demands, and requests shall be deemed given when mailed, postage prepaid, registered or certified mail, return receipt requested, or sent by prepaid express delivery service:

    If to CELLTEX:
    CELLTEX THERAPEUTICS CORPORATION
    2401 Fountain View Drive Suite 416
    Houston, TX 77057 Attention: Lynn Graham Facsimile: (713) 780-0886


    If to Client:
    Mailing Address designated on Celltex Stem Cell Banking Enrollment Form.
  14. HEALTH INFORMATION AND STEM CELL INFORMATION CONFIDENTIALITY: I understand that information about my health may be used or disclosed for the purposes of conducting any clinical study in which I may enroll that involves the use of my stem cells. This information may include information from my medical record that is relevant to the study, such as medical history, medications, test results, diagnoses, treatments, operative reports (reports from operations that I have undergone), and discharge summaries. Information collected by the study investigator and/or research staff specifically for the study, such as test results, information about possible side effects and surveys I might be ask to complete, could also be used or disclosed. Where possible, my identity in any study will be coded for confidentiality.

    Individuals that may use or release this information include: physicians, physicians’ office staff, hospital staff, the study director, and authorized members of the study’s research staff. These individuals may release my information to the study investigator, authorized members of the study staff, the sponsor (Celltex) of the study, sponsor’s representatives or agents, Institutional Review Board (IRB), or regulatory agencies, as required by law.

    I understand that I may have access to data related to my treatment obtained in Celltex-sponsored research, at Celltex’s discretion.
  15. MISCELLANEOUS:
    1. General Confidentiality: The Parties acknowledge and agree that disclosure by the other Party of this Agreement and the information contained herein ("Confidential Information") would be extremely damaging. Each Party agrees that it shall not copy or divulge to any third party any the Confidential Information without the prior written consent of the other Party. Confidential Information shall not include information which becomes public or becomes available on a non-confidential basis from a source other than CELLTEX or me.
    2. Licenses and Permits: CELLTEX represents and warrants that it has acquired and shall maintain all required licenses and permits pertaining to its operations during the Term of this Agreement.
    3. Quality Assurance Activities: CELLTEX agrees to perform any quality assurance activities required by applicable law.
    4. Assignment: The Client may not assign or transfer any of its rights under this Agreement without the prior written consent of CELLTEX.
    5. Further Documents: The Parties do hereby covenant and agree that they and their successors and assigns will execute any and all agreements, releases, assignments and consents which may reasonably be required of them in order to carry out the provisions of this Agreement. Notwithstanding expiration or termination of this Agreement, each Party hereto shall take such further actions as are necessary to fulfill its existing obligations, which by their terms require performance after expiration or termination of this Agreement.
    6. Entire Agreement: This Agreement and the documents referred to herein contain the entire agreement between the Parties relating to the subject matter of this Agreement with the sole exception of materials associated with any clinical studies sponsored by Celltex. Celltex may modify or amend the terms of this agreement by sending notice to the Client a written copy of the modification or amendment and its effective date.
    7. Governing Law: This Agreement shall be governed by and construed, interpreted, and enforced pursuant to the laws of the State of Texas and the United States of America, without giving effect to Texas choice of law rules. Any dispute arising from this agreement shall be resolved only in the state courts in the State of Texas.
    8. No Waiver: The failure of any Party to insist at any time upon the strict observance or performance of any of the provisions of this Agreement shall not impair any such right or remedy or be construed to be a waiver or relinquishment. Every right and remedy given by this Agreement to the Parties may be exercised from time to time and as often as may be deemed expedient by the Parties.
    9. Enforceability, Severability: The invalidity or unenforceability of any term or provision of this Agreement shall not, unless otherwise specified, affect the validity or enforceability of any other term or provision, unless the term or provision is material and its invalidity or unenforceability results in a substantial economic detriment to me or CELLTEX, in which event the Parties hereto shall negotiate in good faith a resolution which to the maximum extent feasible preserves to each Party the rights and benefits contemplated hereunder.
    10. Force Majeure: The inability of CELLTEX to perform any obligations under this Agreement, by reason of fire, earthquake, or other casualty or accident, strikes or labor disputes, disruption of utilities or public services, war or other violence, or any law, order, proclamation, ordinance, demand, or requirement of any government agency, or any other act or occurrence that is beyond the control of CELLTEX, is excused for so long as said cause exists.
    11. Acknowledgement: I acknowledge that I have read and understood this Agreement, that I have had an opportunity to have any of my questions answered to my satisfaction, that I have had an opportunity to seek legal counsel to advise me about this Agreement, and that I am at least 18 years of age.
    12. Electronic Signature: I agree that my initials and electronic signature is legal, valid, and enforceable in every respect as an original signature.

 

 

Celltex Logo CELLTEX THERAPEUTICS CORPORATION

Date: 06/23/2017

Click here to agree to this client services agreement

 

 

The enrollment fee is a one-time banking fee that covers all the lab services required to bank the cells.

A $150 yearly banking fee will also apply on the one-year anniversary of your cell banking date and each subsequent year thereafter.

One Time Payment

Final Cost:

The enrollment fee is a one-time banking fee that covers all the lab services required to bank the cells. The yearly banking fee is paid in advance for the following year. The next yearly banking fee will paid on the anniversary date of your fat extraction.