Hospital Registration


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Welcome to the Cord Blood Program at Vitalant

All information shared with Vitalant is kept confidential and not shared with a third party.

If you have visited our website before and created an account, please login using your username and password. Please review your account after signing in to make sure that all information is correct.

(Please note that items marked with * are required fields to process your request.)

	Select Your Staff Position
	Collector L&D Staff Lab/BB Staff

First Name*
Middle Initial
Last Name*
Title*
Region*
	Select Hospital Affiliated / Privileges

Group / Practice Name
Team Color (if applicable)
Office Address*
City*
State*
Zip Code*
Office phone number*

Cell phone number

Email*

	Create your account
	For security purposes, please ensure your selected password is a minimum of 8 characters in length and contains at least 1 non-alphanumeric character.

User Name*

Password*
Confirm Password*
Security Question*
Security Answer*
	By submitting this information, I am acknowledging that the information contained in this form is correct to the best of my knowledge.