Safetycord » Enrollment

Registering with Safetycord is quick and easy. Simply fill in the online registration information and click send. This process takes only a few minutes but, if you prefer, you can call us and one of our representatives will help you immediately and guide you through the process.

DEAR MOTHER

Fields marked with an asterisk * are mandatory.

* Have you used our services previously?

Yes

PERSONAL DATA

Please provide at least one mobile number and email address.

*Mother's First Name: *Mother's Maiden Name:

*Mother's Date of Birth:

*Mother's Mobile / Cell: (Ej: +45 36992673) Mother's E-mail: (Ej: maria@safetycord.com)

Father's First Name: Father's Last Name: Father's Mobile / Cell: (Ej: +45 36992673) Father's E-mail: (Ej: juan@safetycord.com)

BIRTH DATA

*Expected Delivery Date:

*¿Multiple Birth?

Kits No.:

*Name of your Gynecologist:

*Hospital Name: *Hospital Country:
Birth Preparation Course: (For Example: Dignity Health)

KIT DELIVERY ADDRESS

Please do not indicate the Hospital's address, as they are not responsible for receiving or handing over the kit.

*Country:
*State:
*City:

*Zip Code:
*Address: *Contact Phone Number:

REFERRAL PROGRAM

Do you have a guest code? Type it here

DISCOUNT COUPON

Do you have a discount coupon? Type it here VALIDATE

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Invalid coupon, please review it.

Valid coupon discount will appear when payment is fullfilled.

COMMENTS

If you wish, you may write any comments or give us delivery instructions below

SIGNATURE

* My laboratory is Vitalant Clinical Services.

* I accept terms & conditions. To view or download the contract you have to select the Hospital Country.