First Name *

Last Name *

Email *

Phone Number *

Date of birth *

What's your age?

Your Gender *

Male

Female

Address *

City *

State *

Postal code *

Necessary Medical Information

Weight *

Height *

Have you ever had an organ transplant? *

Yes

Are you taking any anti-rejection medications? *

Yes

Do you have any allergies to medications? *

Please list any medications you’re taking below

Are you taking any blood thinners or anti-inflammatory medications? *

Yes

Do you have any of the following diagnoses? *

Heart Disease
Active Gout Infection
Active Cancer
Multiple Sclerosis
Ankylosing Spondylosis
Pregnancy
Kidney Disease
Diabetes
Rheumatoid Arthritis
Lupus
Amyotrophic Lateral Sclerosis (ALS)
None of These Apply
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If diabetic, is your diabetes controlled or uncontrolled?

Controlled

Uncontrolled

If diabetic, what is your A1C?

If you have Kidney Disease, are you on dialysis?

Yes

If you have active cancer, are you doing one or more of the following treatments?

Chemotherapy

Radiation

No treatments for active cancer

Which team member did you work with?

Adam Berge
Benjamin Nelson
Dasa'n Fant
David Chavez
James Rivers
Karl Canniff
Noah Nelson
Reggie Lynch
Robert Monroe
Seth Berge
Theodore Clemens
Jared Novack
Advert Logix
Tyler Bearden
Chris Ehrlich
Julie Kennedy - Seed Wellness
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What treatments are you interested in exploring? (Select all that apply) *

Regenerative Therapy
Peptides
HRT/TRT
Other
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Regenerative Therapies Questionnaire

Primary Reason for Seeking Stem Cell Treatment *

Is your range of motion limited?

Yes

If multiple body parts are selected for treatment, please specify which body part has limited range of motion by explaining here

Is the pain muscular or trigger point?

Pain Muscular

Trigger Point

If multiple body parts are selected for treatment, please specify the body part and what type of pain for each by explaining below.

Does the pain radiate down any extremity?

If it is a body part, how long have you had these concerns?

If you have seen a physician, what was the diagnosis?

Do you see a pain management specialist?

Yes

What steps have you taken to address the problem(s) you've experienced? *

NSAIDS
CBD
Chiropractic
Acupuncture
Surgery
Narcotic Pain Meds
Cortisone/Steroid Injections
Massage
Physical Therapy
Epidural
Ablation
Other
None of These Apply
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If applicable, what other steps have you taken?

Did any of the above therapies provide relief?

Do you have difficulty having labs drawn or receiving an IV? *

Yes

If you have had surgery on the areas you mentioned above, please give us a date along with which areas and any outcomes (good or bad).

Any other useful information?

Thank you for completing the pre-screen survey!

You'll hear from our team within 72 hours to complete payment and finalize your treatment agreement. After this, your assigned medical provider will reach out to schedule your treatment. Treatment will typically be scheduled within 12 business days.

If you're interested in peptides and/or HRT, you'll be contacted by a member of our team with an additional questionnaire from our medical provider.

If you have any questions or comments or if you selected "other" in the treatments dropdown, you can put them in the below text box.

Questions / Comments / Other