Full Name
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Phone
*
Email
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Gender:
*
Gender:
Preferred Name
Date Of Birth
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Select Date
Weight
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Height
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Primary Care Provider
Phone Number
Referring Provider
(If applicable)
Referring Phone Number
Emergency Contact:
Emergency Contact
*
Emergency Contact Number
*
Primary condition or concern you are seeking evaluation for
Affected area of the body:
When did your symptoms begin?
(Approximate. date)
Current Symptoms
On a scale of 0 to 10, how much does this condition impact your daily life?
Briefly describe how this condition affects your daily activities, work, or mobility
Have you been evaluated by a physician for this condition?
Yes
No
If yes, please list the type of provider (orthopedic, neurologist, pain management, etc.) and approximate date of visit
Provider
Approx. Date of Visit
Approximate date is acceptable. You may enter just the month and year, or only the year (e.g., September 2025, September 5, 2025, or 2025).
Have you had imaging or diagnostic testing related to this condition?
Yes
No
If yes, please select all that apply and provide details:
If Others (please specify):
For each study, please provide:
Type of Imaging
Approximate Date
Facility/Location
Please upload copies of imaging reports and/or bring access instructions if images are stored electronically.
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Please list any treatments you have already tried for this condition and, if known, whether they helped
Examples include: Physical therapy Injections Surgery Medications Chiropractic care Other therapies.
Please check any that apply:
Cancer diagnosis or cancer treatment within the last 5 years
Autoimmune disease
Immune deficiency
Chronic or recurrent infections
Diabetes
Heart disease
Stroke or TIA
Blood clot history
Liver disease
Bleeding disorder
Neurologic disease
Organ transplant history
Kidney Disease
Pregnant, planning to get pregnant or breastfeeding/nursing
If any are checked, please provide brief details including diagnosis and approximate dates.
Please list any known allergies and reactions, including medications, food, latex, contrast, or others.
Please list all prescription medications you currently take, including dose and frequency.
Please list all supplements, vitamins, or hormone therapies you take regularly
IMPORTANT: Please clearly identify if you are taking any of the following:
Blood thinners
Immunosuppressive medications
Steroids such as prednisone
Major Surgery
1
2
3
Approx. Dates
1
2
3
Do you currently use tobacco or nicotine products?
*
Yes
No
Do you drink alcohol?
*
Yes
No
Do you use marijuana or other substances?
*
Yes
No
What are your top goals for this consultation?
What would you personally consider a meaningful improvement?
When are you hoping to begin your stem cell journey?
*
Do you have Global Entry?
Yes
No
If you are traveling in, would you like assistance with any of the following:
Hotel recommendations
Travel timing questions
Others (Please specify):
Example: wheelchair assistance, oxygen support, traveling with medical equipment, companion assistance, etc.
Will you be traveling with a companion?
Yes
No
If yes, how many and with whom?
Example: With one companion, my daughter. Or with one companion, my private nurse.
Terms & Conditions
*
I understand that completion of this form does not guarantee treatment. I acknowledge that all care decisions are made by the physician after review of my medical history, records, and consultation.
Confirmed That All Information Are True
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I confirm that the information provided is accurate to the best of my knowledge.
Signature
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Date signed
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