Medical Intake

Patient General Information

Full Name *

First Name*

Mid. Init.

Last Name*

Email Address *

Email Address*

Date of Birth *

Date of Birth*

Age *

Age*

Gender

Gender*

Physical Characteristics *

Height (ft)*

Height (in)*

Weight*

Primary Phone *

Primary Phone*

Alternate Phone

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*

Medical Information

Please list previous treatments and dates:*

What are you seeking treatment for?*

Current complaints/symptoms*

Current list of medications:*

Do you have any allergies? Please list any below:*

Do you have any medical conditions you have been diagnosed with? If yes, please provide below and when you were diagnosed:*

Do you have or have had a history of cancer? If yes, please provide type below and when you were diagnosed: as well as current status:*

What are you looking to accomplish with this therapy?*

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.

I confirm that I have read and understand all of the statements above.

This field is hidden when viewing the form

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 Intake Form

Patient General Information

Patient Geographic Information

Emergency Contact Information

Medical Information

Patient Application Statement and Agreement