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Welcome to the Stem Cell Institute Patient Application Form.

Please take your time to read each question carefully.

If you have any questions, please contact your clinic representative directly.

❗Important: If you are under 18 years of age, a parent or legal guardian must assist you in completing this form.

👤PERSONAL INFORMATION
Clinic Location :
Were you referred?
Referred by whom? How did you first learn about us?*
Salutation:
Marital Status*:
Occupation*
Legal First Name (as on license or passport)*
Legal Middle Name (as on license or passport)
Legal Last Name (as on license or passport)*
Date of Birth*
Weight (pounds)*
Height* :
Gender*
City / Province* :
Address 1* :
Address 2:
State or Province :
Zip or Country Code* :
Country* :
Time Zone* :

IMPORTANT: One of our physicians might need to speak with you (or the applicant's representative) personally. Please list the single best phone number to reach you, Monday – Friday 10 AM – 7PM, Central Standard Time (international, GMT – 6).

📞CONTACT INFORMATION
Best Phone to reach you* : (include area code)
Work Phone : (include area code)
Cell Phone : (include area code)
FAX Number: (include area code)
Email address* :

🛡️PARENT OR GUARDIAN INFORMATION
Name* :
Address* :
Home Phone* : (include area code)
Office Phone: (include area code)
Cell Phone: (include area code)
Alternate Phone: (include area code)

♿ASSISTANCE
*Need Assistance Walking? Yes No
*Wheel Chair Needed? Yes No
Other Needs :

🚨Emergency Contact
Name* :
Relationship* :
Phone* : (include area code)
City / Province* :
Address 1* :
Address 2:
State or Province:
Zip or Country Code* :
Country:

🩺 HEALTH INFORMATION: Primary Diagnosis/Disease
Physician Name* :
Physician Phone: (include area code)
Primary Disease Diagnosis* :
Primary Symptoms/Medical Conditions:* :
Date of Diagnosis* :
Medical Records Available?
Current Medications:
Anticoagulated?
Anticoagulated Since When:
Why Anticoagulated?

🩺 HEALTH INFORMATION: Cancer history
*Have you ever been diagnosed with any type of cancer? Yes No
Cancer Type:
Date Cancer Diagnosed:
Cancer Status:

🩺 HEALTH INFORMATION: Diabetes history
Are You Diabetic?
Taking Insulin?

🩺 HEALTH INFORMATION: Neurological System
Vision Decrease?
Vision Black Spots?
Vision Nistagmus?
Muscle Weakness?
Muscle Wasting?
Walking Difficulties?
Decreased Hand Strength?
Fainting?
Speech Problems?
Tingling Sensation?
Muscle Fasciculations?
Spasticity?
Hyperreflexia?
Hyporeflexia?
Depression?
Loss of Memory?
Headaches?
Sleep Disturbances?
Dizziness?

🩺 HEALTH INFORMATION: Pulmonary System
Asthma?
Chronic Bronchitis?
Chronic Cough?
Emphysema?
Tuberculosis?

🩺 HEALTH INFORMATION: Cardiovascular Problems
Myocardial Infarction?
Myocardial Infarction Date:
Angina Pectoris?
Tachycardia?
By-Pass Surgery?
By-Pass Surgery Date:
Hypertension (high blood pressure)?
Hypotension (low blood pressure)?

🩺 HEALTH INFORMATION: Circulatory
Poor Arterial Circulation?
Poor Venous Circulation?
Leg Cramps?
Tired Legs?
Swollen Ankles?
Varicose Veins?
Tingling Sensation in Arms and Legs?
Falling Asleep of the Hands and Legs?
*Ulcers or open wounds anywhere on your body? Yes No

🩺 HEALTH INFORMATION: Gastrointestinal Problems
Acid Indigestion?
Bloating?
Stomach or Duodenal Ulcer?
Stomach or Duodenal Ulcer Date:
Loss of Appetite?
Rapid Weight Gain?
Rapid Weight Loss?
Overweight Problem?
Have You Had Upper GI endoscopy?
Upper GI Date:
Upper GI Results:
Hepatitis?
Hepatitis Type:
Gall Bladder Problems?
Gall Stones?
Icterus?
Recurring Diarrhea?

🩺 HEALTH INFORMATION: Upper Respiratory Test
*Chronic Sinusitis? Yes No
*Allergic Sinus Problem? Yes No
*Chronic Allergic Rhinitis? Yes No
*Sinus Headaches? Yes No
*Chronic Nose Bleeds? Yes No
*Chronic Colds? Yes No

🩺 HEALTH INFORMATION: Rheumatic Screen
Soft Tissue Rheumatism?
Articular Rheumatism?
Joint Pain?
Back Pain?
Rheumatoid Arthritis?
Other Rheumatic Conditions:

🩺 HEALTH INFORMATION: Endocrinological System
Diabetes Mellitus?
Overactive Thyroid?
Underactive Thyroid?
Adrenal Gland Dysfunction?
Female Menopause?
Male Menopause?
Other Endocrinological Conditions:

🩺 HEALTH INFORMATION: Allergy
*Food Allergy, Especially Eggs? Yes No
*Hay Fever? Yes No
*Allergic Asthma? Yes No
*Medication Allergies? Yes No
Medication Allergy Symptoms:
*Allergies to any vaccinations? Yes No

🩺 HEALTH INFORMATION: Other
When was your last vaccination?
*Do You Smoke Cigarettes? Yes No
*Do You Smoke Cigars? Yes No
*Do You Smoke Pipes? Yes No
How Much Do You Smoke Per Day?
*Do you drink wine? Yes No
*Do you drink beer? Yes No
*Do you drink hard liquor? Yes No
How much do you typically drink per day?
*Please list any nutritional supplements you are taking:
*Other Significant or Chronic Illnesses :
Do You Take Human Growth Hormone?
How Long Have You Taken Growth Hormone?
Human Growth Hormone Injections per Week:
PSA Test (Men Only)?
PSA Test Date:
PSA Test Result:
Periodic Mammograms

(Women only)?

Mammogram Test Date:
Mammogram test result:

🩺 HEALTH INFORMATION: Surgical/Hospitalizations
Surgical Procedure 1:
Surgical Procedure 1 Date:
Surgical Procedure 2:
Surgical Procedure 2 Date:
Surgical Procedure 3:
Surgical Procedure 3 Date:
Other Surgical Procedures:

🩺 HEALTH INFORMATION: Family History
Has any member of your family had any of the following:
Hypoglycemia?
Diabetes?
Thyroid Problem?
Hormone Problem?
Cancer?
High Blood Pressure?
Kidney Problem?
Heart Problem?
Leukemia?
Arthritis?
Prostate Problem?
Mental Disorder?
Anxiety?
Lung Problem?
Fatigue?
Stroke?
Do you have any questions or comments?:

✔️APPLICATION SUBMISSION: Please read carefully.

By clicking "Submit":

  • I attest that all information I have provided on this form is accurate and complete.
  • I understand that inaccurate or incomplete information may result in denial of treatment.
  • I confirm that I have read and understand the following information:
    • The science of treatment with adult stem cells is in its infancy.
    • The treatments described on cellmedicine.com have not been evaluated by the US FDA and are not considered to be standard of care for any condition or disease.
    • There could be significant and unknown risks associated with adult stem cell treatments, as long-term studies have not been performed.
    • For most diseases, no prospective, randomized clinical trials of adult stem cells have been performed, therefore no guarantee of safety or effectiveness is made or implied.
    • Treatments by licensed doctors will only be performed after the patient understands and agrees to informed consent.
    • The results of testimonials of people who appear on this website who have undergone stem cell treatment are not necessarily typical.
    • If you are accepted for treatment by a doctor, the treatment will not be performed in the USA or Canada. It will be performed in Panama City, Panama.
    • Processing may take up to a minute.
    • A new web page will load to confirm receipt of your application.
    • Applications take up to 5 working days to review from the first working day they are received.

❗After you click the Submit button, please do not reload this page or click your browser's back button.