New Patient Registration
New Patient Registration for Vancouver Stem Cell Treatment Centre

Thank you for completely and accurately filling in your information.

Email address *
Full Name *
Your answer
Date of Birth (mm/dd/yy) *
Your answer
Gender *
Full Mailing Address (including Street number & name, City, Province/State and Postal/Zip Code) *
Your answer
Daytime phone *
Your answer
Night time phone
Your answer
Emergency Contact (name and number) *
Your answer
What is your height? *
Your answer
What is your weight? (lbs/kg) *
Your answer
What is your waist size? (inches) *
Your answer
What is your occupation? *
Your answer
PHN (personal health care number / care care number)
Your answer
Who referred you? / How did you hear about us?
Your answer
Area of concern/symptoms
Please provide as much information as possible.
Primary concern(s) you want Stem Cell Therapy to address *
Your answer
What are your main symptoms? *
Your answer
Date of injury (if any):
Your answer
Health History
If none, please indicate "n/a" in the answer field below.
Please list any medical issues that you have: (e.g. diabetes, high blood pressure, heart or lung problems, cancer, etc.) *
Your answer
Please list any imaging reports that you may have had (e.g. computed tomography (CT), magnetic resonance imaging (MRI), X-rays, etc.): *
Your answer
X-Rays, MRIs, CT Scans etc...
Note: IF YOU HAVE COPIES of the Imaging REPORTS, please email them to info@vanstemcell.com
We collect both the intake form as well as your imaging reports to form a complete picture and assess your condition.
Please list any surgeries you have had: *
Your answer
Have you encountered any complications in past surgical procedures? If so, what were the complications? *
Your answer
Please list any medications or supplements that you presently take (including Aspirin, acetaminophen, ibuprofen or NSAIDs) *
Your answer
Have you every taken any of the following medications? *Check all that apply *
Required
Any Medication/Environmental Allergies? Please list. *
Your answer
Have you or any of your family members experienced any complications with anaesthetics? *
Your answer
Have you ever had or currently Hepatitis, HIV, or any other blood borne diseases? If so, what? *
Your answer
What is your average blood pressure? *
Your answer
Do you smoke? If so, how frequently? *
Your answer
How much alcohol, if any, do you consume in a week? *
Your answer
If this is a sport related problem, please list your sports/activities: *
Your answer
Have you ever had experience with stem cell therapy and/or Platelet-Rich Plasma (PRP)? *
Your answer
If so, when and where? *
Your answer
Additional Information
NOTE: Please SUBMIT THIS FORM with before DOWNLOADING EACH ARTICLE. THIS FORM CAN BE REOPENED AFTERWARDS. All links will also be shown after submitting this form.

Below you will find links to several documents/articles that you should read prior to your appointment.
Note that both links will pop up in a separate tab.

Check both boxes once you have clicked on each link to open.
Checking of these boxes certifies that "Yes, I have opened and downloaded and/or read the articles indicated."

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