Our Cells

PATIENT APPLICATION FORM

All questions contained in this questionnaire are strictly confidential and will become
part of your medical record.

    PERSONAL INFORMATION

    One of our Patient Services representative will reach out to you if further information needed, please specify single best number to reach you, including country code

    Name:

    Last name:

    Gender:

    Weight in kg:

    Address:

    Email:

    Phone:

    Marital status:

    Race:

    EMERGENCY CONTACT

    Name:

    Last name:

    Phone:

    Address:

    Relationship:

    SOCIAL HISTORY

    Do you smoke cigarettes?

    YESNO

    If yes, for how many years?

    Currently how many per day?

    Do you currently drink alcohol?

    If yes, for how many years, Currently how many drinks per week?

    MEDICAL HISTORY

    Please list ALL medical history, past and current

    Have you ever been diagnosed with any type of cancer?

    YESNO

    If yes, please list what type:

    SURGICAL HISTORY

    Date Reason Hospital

    CURRENT MEDICATIONS & DOSAGE

    List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

    Medication Dosage Frequency Taken

    PHYSICAL LIMITATIONS:

    Need assistance walking

    Are you currently taking any human growth hormones or doing hormone replacement therapy?

    YESNO

    If yes, HRT amount and for how long? Number of IU’s of HGH injected per week and for how long?

    ALLERGIES:

    Are you allergic to any foods, especially eggs?

    YESNO

    Please list:

    Are you allergic to any vaccinations?

    YESNO

    Please list:

    Name of medication Reaction You Had?

    PRIMARY DIAGNOSIS/DISEASE:

    Reason for stem cell therapy:

    FAMILY PHYSICIAN:

    Name:

    Last name:

    Phone:

    Address:

    Date of your last medical checkup:

    Have you ever had stem cell treatments before?

    YESNO

    If yes, Location of treatment:

    Efficacy (ameliorate) after treatment:

    Any adverse effects after treatment?

    YESNO

    Please specify:

    What do you intend to accomplish with the treatment you are seeking?

    DISCLAIMER

    • By submitting this form, I attest that all information is accurate and real

    • I confirm that I understand that adult stem cell treatments have not been evaluated by the FDA and are currently not standard of care for any of the conditions we treat

    • There are risks associated with stem cell treatments

    • Treatments are not covered by local or international insurance

    • We do not provide itemized bills

    • This treatment is not part of a clinical trial