Medical History

First Name

Last Name

Phone

Age

Sex

Weight

Why do you want stem cell treatment? (please check all that apply)
Select all that apply

Anti-aging Autoimmune disease Joint injection Cosmetic Spine conditions/back problems Hip problems Heart problems Neurological disorder Other

Do you have any allergies or have you had any allergic reactions to medications in the past? What conditions or disease(s) do you suffer from? How long ago did the symptoms begin? What type of treatment or medications have you tried to help with your condition or symptoms? Primary reason for wanting stem cell treatment? What medications are you currently taking?

***For all joint and/or spine treatments, please send the corresponding imagery (X-rays and/MRI). Without the corresponding imagery for your condition, the lab cannot accurately recommend treatment and will cause a delay in response time.

Upload Imagery

Drop files here or

Doctor recommending treatment (if applicable)

Doctor's Name

Clinic

Clinic Phone

Clinic Email