Client Medical Disclosure Questionnaire

We are excited that you have scheduled your Stem Cell appointment. Please fill out the questionnaire

Full Name

Date of birth

Phone *

Email *

Emergency Contact Name & Phone:

Address

Street Address

City

State

Country

Postal Code

Medical Safety Disclosure

If Yes, briefly describe your medical conditions (1–2 lines):

Medications & Treatments

If Yes, list or describe your Medications & Treatments:

Recent Procedures or Infections

In the past 90 days, have you had:

Surgery

Hospitalization

Active infection

Fever or unexplained illness

Have you had adverse reactions to injections, IV therapy, or biologic products?

Yes, I have

No, I have not

Have you ever been advised by a medical professional not to receive IVs or Stem Cells?

Yes

Additional Medical Information

Is there any medical condition, diagnosis, treatment, or history not listed above that a reasonable medical provider should know before administering this treatment?

Yes

If Yes to Additional Medical Information, briefly explain:

Patient Acknowledgments & Attestations

I acknowledge and agree that I am solely responsible for fully and accurately disclosing any and all relevant medical conditions, diagnoses, medications, treatments, allergies, infections, or health-related information that may affect the safety or outcome of this treatment.

I understand that failure to disclose complete and accurate information may increase the risk of complications, adverse reactions, or unsatisfactory results, and I accept full responsibility for any consequences resulting from incomplete, inaccurate, or omitted disclosures.

I further understand and agree that this medical questionnaire is intended to supplement, but not replace, the Informed Consent document, and that both documents are part of my agreement to proceed with this elective and investigational treatment.

Patient Acknowledgments & Attestations: Please check each statement: *

I certify that the information provided above is complete, accurate, and truthful to the best of my knowledge.

I understand this treatment involves human cellular or biologic products and is considered elective and investigational.

I understand results are not guaranteed, and individual outcomes vary.

I understand I am responsible for disclosing any relevant medical changes prior to treatment.

I understand this questionnaire does not replace consultation with my primary care physician.

I understand that failure to disclose relevant medical information may increase risk and may result in adverse outcomes for which the clinic and medical staff are not responsible.

I understand this treatment is not FDA approved

Please Select Todays Date

Signature (medical quesionnaire)

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