First Name *

Last Name *

Date of Birth *

Patient's Bodyweight in Kilos *

Phone *

City *

State *

Country *

Email *

Clinic City *

I understand that the Regenamex treatment cost begins at $2,000 USD. However, please note that travel and accommodation expenses are not covered.

Yes

Are You Able to Travel Internationally?

Regenamex is situated in Mexico, and for candidates to undergo treatment at our clinic, they must be physically, mentally, and legally capable of traveling. If you have mobility issues, traveling with a companion will be necessary.

Yes

Is the candidate pregnant or at risk of being so?

Yes

Is candidate diagnosed with any type of cancer?

Yes

For what purpose are stem cells needed?

Stem Cells For Anti-Aging

Stem Cells For Auto-Immune Disease

Stem Cells For Chronic Pain Relief

Stem Cells For Neurological Degeneration

Stem Cells For Sports & Orthopedic Injuries

Stem Cells For Anti-Aging

Facial and Neck Rejuvenation

Cellular Degeneration to Cellular Regeneration Enhancement

Give Us a Detailed Description of All the Symptoms That Go Along With Your Muscle / Skeletal Issues

Upload Files like Xrays no more than 15MB and no more than 6 files at a time

Submit Medical reports

Explain the most concerning issues about your health?

What kind of symptoms do you have?

Have you had a consultation with a doctor?

Yes

What Was the Outcome of Your Diagnosis?

Please List All Medical Conditions You Have, Past and Present:

Please List All Medications and the Current Dosage That You Are Currently Taking:

Allergies?

Yes

If You Answer Yes to Allergies, Which Ones?

Surgeries?

Yes

If You Answer Yes to Surgeries, Which Ones?

Smoking?

Yes

Alcoholism?

Yes

Do you have high blood pressure?

Yes

Do you have accommodations?

Yes

If you've already booked accommodation, where is it? If not, we have an all-inclusive option. What are your dates?

If You Have Confirmation of Your Flight, Send Us Your Itinerary:

What Are Your Potential Ideal Bookings Dates for Your Trip to Wellness?

What Is His/Her Name?

Who Was Your Patient Advisor?

Renenamex Disclaimer

Due to Regenamex Clinic's growth, we're experiencing longer wait times for processing medical intake forms, which can take over two weeks. To fast-track, provide flight details as a deposit, which helps prioritize your case. We apologize for any delays and are committed to responding promptly and providing honest feedback. Best, Daniel Carruthers & the Regenamex Team