Your First Name
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Email
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Phone
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1) Please select the medical condition that best describes your case below.
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Arthritis
Autoimmune
Crohn's Disease
Osteoarthritis
Fibromyalgia/Chronic Pain
Heart Failure
Lupus
Lyme Disease
Multiple Sclerosis
Neurological
Rheumatoid Arthritis
Traumatic Brain Injury
Ulcerative Colitis
Chronic Pain
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2) Please describe your current symptoms and medical history. Providing detailed information will help speed up the application process.
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3) BioGenesis is located in Panama City, Panama. Candidate must be able to physically and mentally able to travel to our clinic for treatment. Are you capable of international travel?
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Yes
No
4) I understand that this is a patient-funded program and treatment cost starts at $10,750 USD. Accommodation is included. Travel not included
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Yes, I have the resources available for this treatment
No, this investment is beyond my financial means
5) I understand that our medical team dedicates significant time to reviewing each patient's case. If I need to reschedule, I will provide advance notice.
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Yes, I agree, I will show up on time, this is important to me.
No, I don't agree, I'm not sure I'll attend.
6) Are you over 18 years old without an active cancer diagnosis, pregnancy, or active viral infections (HIV/AIDS)?
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Yes, I confirm I meet all eligibility requirements
No, I have one or more of these conditions
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