To confirm, you are filling this out because you are interested in a stem cell treatment?
Yes
No
Where is your pain located?
Knee
Hip
Shoulder
Back
Other
How long have you had this pain?
Less than 3 months
3–6 months
6–12 months
Over 1 year
Have you tried other treatments before?
Pain meds
Injections
Physical therapy
Surgery / Considering surgery
Haven’t tried anything yet
Are you actively looking for a non-surgical solution?
Yes, ASAP
Possibly
No
How is this pain affecting your life?
I can’t sleep well
It’s affecting my mobility
I’ve stopped exercising
It’s interfering with work or daily activities
I’m in constant pain
Not much, just annoying
If approved for treatment, are you ready to come to Mexico in the next 30 days to finally get relief from your chronic pain? (Travel expenses will be covered)
*
Yes
No
Where should we send your results?
First Name
Phone
*
Email
*