Intake Form - Patient

Patient Information

Full Name *

Date of Birth *

Gender *

Male

Female

City *

State *

ZIP Code *

Country:

Phone Number *

Email Address *

Referral Information

How did you hear about us?

Caller Information (if different from patient):

Are you the Patient ? *

Yes

Incident and Accident History

Have you been involved in any accidents or incidents that medical treatment?

Yes

Current Health Information

Describe any current health issues or symptoms

Current pain level

Where is the pain located?

How long have you been experiencing this pain?

Is the pain neurological, immune-related, or joint-related?

How serious is the pain?

Do you have any immune system issues or joint pain?

Yes

Medical History

List any past or current medical conditions

List any surgeries or hospitalizations

Are you currently taking any medications?

Yes

Do you have any allergies?

Yes

Do you have all your medical records for the past year?

Yes

Would you like us to help obtain them?

Yes

Upload past medical history records:

Drag & Drop files here OR Click to upload

Medical Imaging / Documents Upload :

Please upload any recent lab results, imaging, scans, diagnostic reports, or other medical records relevant to your condition.(Accepted formats: PDF, JPG, PNG, DOCX. Max size: 10MB)

Drag & Drop files here OR Click to upload

Current Medications & Supplements

Medication Name

Dosage

Frequency

Supplements / Vitamins

Allergies

Do you have any known allergies to medications, foods, or substances?

Yes

Lifestyle & Wellness

Do you smoke?

Yes

Do you consume alcohol?

Yes

Exercise Frequency

Diet Type / Restrictions

Stress Level (1-10)

Sleep Patterns

Treatment Preferences

Prefer treatment at home or centre?

Urgency

When are you looking to schedule the treatment?

Are you interested in stem cell treatments?

Yes

Additional Services

Would you like us to refer you to an American specialist for a second opinion?

Yes

Do you need an MRI or full medical scan?

Yes

Country for MRI

State

City / ZIP

Primary Care Physician

Do you have a primary care physician?

Yes

Physician’s Name:

Physician’s Contact Information:

Physician’s Email:

Physician’s City:

Country

Physician’s State:

Physician’s ZIP Code:

Would you like us to reach out to your primary care physician to obtain your medical records?

Yes

Payment & Insurance

Payment method

Debit/Credit

Insurance

Treatment Preferences:

Would you prefer treatment at home or at a servicing centre?