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Caller's Phone Number:
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Are you the Patient ?YesNo
Caller's Full Name:
Have you been involved in any accidents or incidents that required medical treatment?
YesNo
please describe the incident(s):
Date(s) of incident(s):
Do you have an ongoing case or need a referral for an attorney?
would you like us to refer you to an attorney on our platform?
Describe any current health issues or symptoms:
What is your current pain level?—Please choose an option—LowMediumHigh
Where is the pain located?
How long have you been experiencing this pain?
Is the pain neurological, immune-related, or joint-related?neurologicalimmune-relatedjoint-related
How serious is the pain?
Do you have any immune system issues or joint pain?
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List any past or current medical conditions:
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Do you have any allergies?YesNo
Do you have all your medical records for the past year?YesNo
would you like us to help obtain them?YesNo
Upload past medical history records:
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)
Please list all medications you are currently taking:
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Do you have any known allergies to medications, foods, or substances? YesNo
Please list:
Do you smoke?YesNo
Do you consume alcohol? YesNo
Exercise Frequency:
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Stress Level: —Please choose an option—Stress Level 1Stress Level 2Stress Level 3Stress Leve4Stress Level 5Stress Level 6Stress Level 7Stress Level 8Stress Level 9Stress Level 10
Sleep Patterns:
Autoimmune Disease
Cancer
—Please choose an option—Select Type/Stage/StatusType 1Type 2Stage 1Stage 2ActiveIn Remission
Diabetes (Type 1 or 2)
Heart Disease / High Blood Pressure
Thyroid Issues
Liver / Kidney Disease
Chronic Fatigue / Fibromyalgia
Neurological Disorders
—Please choose an option—Select ConditionALSMSParkinson's
Personal Injury from Accident
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Have you undergone any of the following treatments in the past? —Please choose an option—Chemotherapy / RadiationStem Cell TherapyPRP / ExosomesSurgeriesPhysical TherapyChiropracticHolistic / Integrative MedicineMassage / Manual TherapyNoneOther
Would you prefer treatment at home or at a servicing centre?—Please choose an option—HomeServicing Centre
How urgent is your need for treatment?—Please choose an option—ImmediateWithin a weekWithin a month
When are you looking to schedule the treatment?
Date
Time
Are you interested in stem cell treatments?
Would you like us to refer you to an American specialist for a second opinion?
Do you need an MRI or full medical scan?
Country—Please choose an option—AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Democratic Republic of the)Costa RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth KoreaNorth MacedoniaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe
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Do you have a primary care physician?YesNo
Physician’s Name:
Physician’s Contact Information:
Physician’s Email:
Physician’s City:
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Are you interested in stem cell treatments? —Please choose an option—1 Week2 Weeks3 Weeks4 Weeks
