Patient Application

Personal Information

How did you hear about us or who referred you to us?

Referred by whom? How did you first learn about us?*

Salutation(Required)

Legal First Name (as on license or passport)(Required)

Legal Middle Name (as on license or passport)

Legal Last Name (as on license or passport)(Required)

Date of Birth(Required)

Weight (pounds)(Required)

Height(Required)

Gender(Required)

MALE

FEMALE

Address

Location(Required)

CountryState or Province

City(Required)

Zip or Country Code(Required)

Time Zone(Required)

As soon as we review your Intake Form, one of our physicians might need to speak with you (or a family representative) personally.

What is the best phone number for us to reach you, Monday – Friday 10 AM – 7PM, Central Standard Time?

Best Phone(Required)

Work Phone

Cell Phone

FAX Number

Email(Required)

Occupation

Marital Status(Required)

Married

Unmarried

Divorce

Parent/Guardian Information (if applicable)

Name

First Last

Address

Home Phone

Office Phone

Cell Phone

Alternate Phone

Physical Limitations

Need Assistance Walking?(Required)

Yes

No

Wheel Chair Needed?(Required)

Yes

No

Other Needs

Emergency Contact

Name

First Last

Relationship(Required)

Phone(Required)

Address

Lookup

CountryState or Province

City

Zip or Country Code

Primary Diagnosis/Disease

Physician Name(Required)

Physician Phone

Primary Disease Diagnosis

Primary Symptoms/Medical Conditions:

Date of Diagnosis

Medical Records Available?

Yes

No

Current Medications

Anticoagulated?

Yes

No

Anticoagulated Since When

Anticoagulated?

Yes

No

Why Anticoagulated?

Subject History: Cancer

*Have you ever been diagnosed with any type of cancer?

Cancer Type

Date Cancer Diagnosed

Cancer Status:

Subject History: Diabetes

Are You Diabetic?

Yes

No

Taking Insulin?

Yes

No

Surgical/Hospitalizations

Surgical Procedure 1

Surgical Procedure 1 Date

Surgical Procedure 2

Surgical Procedure 2 Date

Surgical Procedure 3

Surgical Procedure 3 Date

Other Surgical Procedures

By my signature below, I “Submit" 1) I attest that all information I have provided on this form is accurate and complete. 2) I understand that inaccurate or incomplete information may result in denial of treatment. 3) I confirm that I have read and understand the following information:

By completion and returning this application:

I attest that all information I have provided on this form is accurate and complete.
I understand that inaccurate or incomplete information may result in denial of treatment.
I confirm that I have read and understand the following information:
- The science of treatment with adult stem cells is in its infancy.
- The treatments described on LifeAlteringStemCells.com have not been evaluated by the US FDA and are not considered to be standard of care for any condition or disease.
- There could be significant and unknown risks associated with adult stem cell treatments, as long-term studies have not been performed.
- For most diseases, no prospective, randomized clinical trials of adult stem cells have been performed, therefore no guarantee of safety or effectiveness is made or implied.
- Treatments by licensed doctors will only be performed after the patient understands and agrees to informed consent.
- The results of testimonials of people who appear on this website who have undergone stem cell treatment are not necessarily typical.
- If you are accepted for treatment by a doctor, the treatment will not be performed in the USA or Canada. It will be performed in Mazatlan, Mexico.
- Please complete application and email back to: drmark@lifealteringstemcells.com
- Applications may take up to 5 working days to review from the first working day they are received.

Name(Required)

Signature(Required)

Date(Required)

CAPTCHA

Patient Intake Form

Personal Information

How did you hear about us or who referred you to us?

As soon as we review your Intake Form, one of our physicians might need to speak with you (or a family representative) personally.

What is the best phone number for us to reach you, Monday – Friday 10 AM – 7PM, Central Standard Time?

Parent/Guardian Information (if applicable)

Physical Limitations

Emergency Contact

Primary Diagnosis/Disease

Subject History: Cancer

*Have you ever been diagnosed with any type of cancer?

Subject History: Diabetes

Subject History: Neurological System

Subject History: Pulmonary System

Subject History: Cardiovascular Problems

Subject History: Circulatory

Subject History: Gastrointestinal Problems

Subject History: Upper Respiratory Test

Subject History: Rheumatic Screen

Subject History: Endocrinological System

Health History Allergy

Subject History: Other

Surgical/Hospitalizations

Family History

Has any member of your family had any of the following:

By my signature below, I “Submit" 1) I attest that all information I have provided on this form is accurate and complete. 2) I understand that inaccurate or incomplete information may result in denial of treatment. 3) I confirm that I have read and understand the following information:

By completion and returning this application:

United States

Canada

Patient application

Patient Intake Form

Personal Information

How did you hear about us or who referred you to us?

As soon as we review your Intake Form, one of our physicians might need to speak with you (or a family representative) personally.

What is the best phone number for us to reach you, Monday – Friday 10 AM – 7PM, Central Standard Time?

Parent/Guardian Information (if applicable)

Physical Limitations

Emergency Contact

Primary Diagnosis/Disease

Subject History: Cancer

*Have you ever been diagnosed with any type of cancer?

Subject History: Diabetes

Subject History: Neurological System

Subject History: Pulmonary System

Subject History: Cardiovascular Problems

Subject History: Circulatory

Subject History: Gastrointestinal Problems

Subject History: Upper Respiratory Test

Subject History: Rheumatic Screen

Subject History: Endocrinological System

Health History Allergy

Subject History: Other

Surgical/Hospitalizations

Family History

Has any member of your family had any of the following:

By my signature below, I “Submit" 1) I attest that all information I have provided on this form is accurate and complete. 2) I understand that inaccurate or incomplete information may result in denial of treatment. 3) I confirm that I have read and understand the following information:

By completion and returning this application:

United States

Canada

What is the best phone number for us to reach you, Monday – Friday 10 AM – 7PM, Central Standard Time?