PATIENT APPLICATION FORM

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:

—Please choose an option—MaleFemale

Weight in kg:

Address:

Email:

Phone:

Marital status:

—Please choose an option—Single PartneredMarriedSeparatedDivorcedWidowed

Race:

—Please choose an option—CaucasianBlackHispanicAsianOther

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?

YesNoSocially

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:

—Please choose an option—ALSAlzheimer’s DiseaseAnti-agingHeart DiseaseAutismHigh Blood PressureArthritisAutoimmune DisorderVasculitisBrain TraumaCardiovascular DiseaseCerebral PalsyCVA (stroke)Chron’s DiseasePeripheral Artery DiseaseParkinsonsUlcerative ColitisJoint PainMultiple SclerosisAngina/Coronary Heart DiseaseOsteoarthritisLupusSpinal Cord InjuryRheumathoid ArthritisOther

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