Treatment Application & Records Submission PLEASE ALLOW 5-10 SECONDS FOR THE FORM TO LOAD "*" indicates required fields Step 1 of 3 33% Patient's Name* First Last Telephone or Cell Number*Email* Skype User Name What is Your Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country What Condition Are You Diagnosed with?*Select Your Diagnosis BelowALS Amyotrophic Lateral SclerosisAlzheimersAnti-Aging & WellnessArthritisArthritis - RheumatoidAtaxiaAutism Spectrum SyndromeAutoimmune DiseaseBrain Neurodegenerative DiseaseBrain Injuries - TraumaticCancer - LymphomaCancer - LungCancer - LiverCancer - PancreasCancer - OtherCartilage DamageCerebral PalsyCholecystitisCrohns DiseaseCongestive Heart FailureDegenerative Disc Disease (DDD)Diabetes Type 1Diabetes Type 2Diabetic NephropathyDiabetic NeuropathyED - Erectile DysfunctionEndometrial HyperplasiaEnlarged HeartFatty LiverFibromyalgiaHeart DiseaseKidney FailureLiver CirrhosisLiver DiseaseLung Fibrosis - Known CauseLung Fibrosis - IdiopathicLung Disease - COPDLung Disease - EmphysemaLung Disease - BronchiectasisLung Disease - OtherMotor Neuron DiseaseMultiple Sclerosis - MSMultiple System Atrophy - MSAMuscular DystrophyMyasthenia Gravis - AutoimmuneMyopathyOrthopedic Injury - KneeOrthopedic Injury - HipOrthopedic Injury - ShoulderOrthopedic Injury - OtherOsteoathritisOsteoporosisPancreatitisParkinsons DiseasePeripheral NeuropathyPLS - Primary Lateral SclerosisPolycystic Kidney DiseaseSpinal Cord InjuriesSpinal Muscular AtrophySpinocerebellar Ataxia (SCA)StrokeSystemic lupus Erythematosus (SLE)ThalassemiaUlcerative ColitisCOSMETIC STEM CELL THERAPYStem Cell Breast ReconstructionStem Cell Anti-AgingFull Body RejuvenationOTHER TREATMENT- Please describe BelowPatient Gender* Male Female Date Of Birth (DD/MM/YY)* DD slash MM slash YYYY Patients Height* Please Specify Feet/Inches or CMPatients Weight* Please Specify Pounds or KGWhat is Your Occupation? Your Personal Doctor in Your Home Country ( Primary Care Physician ) First Last Office Phone for Your Primary Care Physician (In Case of Records Requests)Name & Telephone Number of your Emergency Contact Person* This Can be Family,Friend or Caretaker Date of Initial Diagnosis* When Were You Initially Diagnosed By A Medical Doctor?Other Medical Conditions, DiagnosesPlease list all Other known medical conditions As completely as you can and list the dates of initial diagnosis.How would you describe your current medical condition?*Do you have or have you suffered from the followings:*Allergies, Vaccination, drugs, hay feverHeart ProblemHigh Blood PressureAsthmaLung DiseaseEpilepsyPsychiatric problems - nervousness, depressionGastrointestinal problemsLiver ProblemsHepatitis AHepatitis BHepatitis CRenal ProblemsKidney ProblemsMusculoskeletal ProblemsOsteoporosisOsteoarthritisBlood DisorderThrombosisDiabetes Type1Diabetes Type2Thyroid DisordeMenopauseHIV/AIDSCancerSurgeryNone of the aboveChoose all that apply (Use CMD or Shift for Multiple)If YES to any choices above, please elaborate:Are you Currently Taking Any of the Following Medications:*ChemotherapyAnticoagulantsAntibioticsSteroidsNone of the aboveChoose all that applyDo you have any of the following Sensory/Motor/Smell/Vision Loss symptoms?Upper limbsUpper limbLower limbsLower limbsThoraxThoraxPelvisPelvisFace below eyesFace below eyesFace above eyesFace above eyesEye Movement AffectedEye Movement AffectedLoss of Sense of SmellLeft Eye Visual Field LossLeft Eye Visual Field LossRight Eye Visual Field LossRight Eye Visual Field LossMild DementiaModerate DementiaSevere DementiaSeizuresNone of the aboveChoose ALL that apply or "None of the Above"Do you have any of the following symptoms?*Difficulty putting words in correct order or contextDifficulty articulating wordsDifficulty finding the correct wordInability to speakInability to identify common objectsAdditional speech difficultiesMild difficulty swallowingModerate difficulty swallowingSevere difficulty swallowingMild difficulty gait impairmentModerate difficulty gait impairmentSevere difficulty gait impairmentBowel incontinenceBladder incontinenceNone of the aboveChoose ALL that applyPlease list all medications you are currently taking, date started, date stopped, dose, and strength.*SmokingAmount per dayWhen startedWhen stopped Add Removeif NONE Please Write “NONE”AlcoholTypeAmount per day or week Add Removeif NONE Please Write “NONE”Family History of Disease:*DiseaseRelationship Add RemoveIf NONE Please Write "NONE"Allergies to any foods, plants, animals, insects or medications?*If "NONE" please Write "NONE"List all Nutritional Supplements You are Taking. Please Include Brand Names and Dosages*If "NONE" please Write "NONE"Please choose one of the followings which best describes your moving ability.*Asymptomatic, fully activeWalks normally, but reposts fatique that interferes with athletic or other demanding activitiesAbnormally gait or episodic imbalances; gait disorder is noticed by family and friends; able to walk 25 feet (8 meters) in 10 seconds or lessWalks independently; able to walk 25 feet in 20 seconds or lessRequires unilateral support (cane or single crutch) to walk; walks 25 feet in 20 seconds or lessRequires bilateral support (canes, crutches, or walker) and walks 25 feet in 25 seconds or less; OR requires unilateral support but needs more than 20 seconds to walk 25 feetRequires bilateral support and more than 20 seconds to walk 25 feet; may use wheelchair on occassionWalking limited to several steps with bilateral support; unable to walk 25 feet; may use wheelchair for most activitiesRestricted to wheelchair; able to transfer self independentlyRestricted to wheelchair; unable to transfer self independently Have you had Stem Cell Therapy In The Past?* Yes No Details About Any Previous Treatments or TherapiesPlease Give Us a Brief Summary of Your Previous Treatments. Surgical or Non-Surgical, How Long Ago,Where & Outcomes.What are your expectations after having cellular therapy?*Do you understand genetic abnormalities can be treated not cured?* Yes No How did you hear about The Regeneration Center?* Word of Mouth (e.g. friend, colleague) Social Media (e.g. Facebook, Twitter, Instagram) Search Engine (e.g. Google, Bing) TV or Print Story Other (please specify) Other - More information on how you found us or additional comments Please include medical reports, MRI, X-ray, CTscan filesAccepted file types: jpg, jpeg, png, gif.(.jpg,.gif,.png,.pdf,.doc format ONLY)Please include medical reports, MRI, X-ray, CTscan filesAccepted file types: jpg, jpeg, png, gif.(.jpg,.gif,.png,.pdf,.doc format ONLY)Please include medical reports, MRI, X-ray, CTscan filesAccepted file types: jpg, jpeg, png, gif.(.jpg,.gif,.png,.pdf,.doc format ONLY)Please include medical reports, MRI, X-ray, CTscan filesAccepted file types: jpg, jpeg, png, gif.If you have more medical records than this online form can accept please please email or postmail the additional records to email@example.com. ==Note== We do not store physical Records / CDs / Reports so please make a copy before sending to us.