Medical History

The form below is to be completed by the patient, or on the patient’s behalf, including detailed responses to all questions that apply to the applicant’s medical history and for which treatment is being considered. These details will assist the medical team in determining if the patient is a candidate for stem cell therapy. Please allow 3-5 business days once all requested medical records have been submitted for the medical review to be completed. Your Care Coordinator will be in contact with you shortly after to help finalize the process.

Please fill out the form as accurately as possible. Thank you!

Asterisk (*) denotes required field.

Medical History Form

"*" indicates required fields

Patient General Information

Full Name *

First Name*

Mid. Init.

Last Name*

Email Address *

Email Address*

Date of Birth *

Date of Birth*

Gender

Gender*

Physical Characteristics *

Height - Feet*

Height - Inches*

Weight*

Primary Phone *

Primary Phone*

Alternate Phone

May we leave a voicemail or text to your primary number?

Marital Status

Age *

Age*

Occupation

Patient Geographic Information

Address*

Address Address 2 City State/Province Postal Code Country

Emergency Contact Information

Full Name *

First Name*

Last Name*

Phone *

Phone*

Relationship *

Relationship*

Are you the patient or legal guardian, representative, or power of attorney of the patient?*

Patient

Legal Guardian/Representative

Power of Attorney

Do you have a copy of the Power of Attorney that can be provided?*

Yes

Legal Guardian/Representative/Power of Attorney General Information

Full Name *

First Name*

Last Name*

Gender *

Gender*

Primary Phone *

Primary Phone*

Alternate Phone

Email Address *

Email Address*

Legal Guardian/Representative/Power of Attorney Geographic Information

Address*

Address City State/Province Postal Code Country

Patient Application Statement and Agreement

Stemedix™ offers adults, doctors, and researchers the opportunity to connect with licensed medical doctors who use stem cells as part of their clinical practice. Stem cell treatment is currently not the standard of care and the following important disclosures are made:

The science of treatment using stem cells is in its infancy.
Treatments described are not approved by the United States FDA and are not considered to be any standard of care for any condition or disease.
There could be significant and unknown risks associated with stem cell treatments, as long term studies have not been performed.
For most diseases, no prospective, randomized clinical trials of stem cells have been performed; therefore, no guarantee of safety is made or implied.
Treatments by licensed doctors will only be performed after the patient understands and agrees to informed consent.

By checking the box below you agree that you have read and understand all of the statements above.

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Patient Agreement

I agree*

I Agree*

Note: Please verify that all required fields are filled in correctly before submitting the form. Once clicking the submit button, you will be taken to a "Thank You" confirmation page. If you are not redirected to the "Thank You" page, scroll up and verify you have filled in all the fields correctly. The form is not submitted until you reach the "thank you" confirmation page. If you are having issues filling out the form, please contact us at 800-531-0831 for assistance.

Medical History

Medical History Form

Patient General Information

Patient Geographic Information

Emergency Contact Information

Legal Guardian/Representative/Power of Attorney General Information

Legal Guardian/Representative/Power of Attorney Geographic Information

Diagnosis Information

Medical Questionnaire

Symptoms

Last Medical Checkup

Patient Application Statement and Agreement