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First Name*
Last Name*
1. Do you have a severe condition or disease?*
Yes
No
2. Please describe the specific type of condition or disease you have (e.g. Osteoarthritis, MS, etc.)*
3. Are you on medication?*
Yes
No
If yes, please describe your medication
4. What one thing would you like to do that your condition prevents you from doing? Please describe*
5. Have you spoken with your Doctor about alternative treatments?*
Yes
No
6. How familiar are you with adult stem cell therapy?*
High
Moderate
Fair
Not at all
7. Would you travel outside the U.S. to receive treatment that has been tested well in clinical trials, is in a facility licensed in a government regulated environment and exceeds U.S. surgical standards of care and technology?*
Yes
No
Maybe
8. Adult stem cell therapy is not covered by medical insurance. Are you able to fund a treatment through private pay or financing?*
Yes
No
9. What is your age?*

Please give us your contact information:

Email*
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treatments:
Complimentary cancer treatments