This form is for relatives of patients in Cleveland Clinic's Blood and Marrow Transplant program to register and to authorize use/disclosure of your health information. By filling out the following form, you are giving Cleveland Clinic permission to contact you regarding your participation in the Blood and Marrow Transplant program for your specified relative. 


NOTE: Non-blood relatives shall not complete this form.  Instead, please visit to register to become a donor.



Please call 216-445-0333 if you have any questions.

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