Stem Cell Candidate Form
Please enter your information so that we can help you determine if you are a candidate for stem cell therapy
Email address *
Name *
Your answer
Email *
Your answer
Phone number *
Your answer
Street Address *
Your answer
City *
Your answer
State/Province/Territory *
Your answer
Country *
Your answer
Please indicate what time (during weekdays) is best for us to contact you to discuss your case (check all that apply) *
Required
What is your primary area of pain? *
Have you had any medical imaging within the last 12 months? (check all that apply) *
Required
How long have you been in pain? *
Please indicate if you have any of the following health conditions (check all that apply): *
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Please tell us more about your pain *
Your answer
I understand that Regenerative Performance does not accept insurance (click the checkbox) *
Required
I understand that regenerative injections, including stem cells, are not covered by insurance (click the checkbox) *
Required
I understand that if I am a stem cell candidate and would like to book an appointment, there is a $500 non-refundable booking fee which is then applied to my final balance on the day of the procedure. *
Required
I understand the wait list for a stem cell procedure may be up to 4-6 weeks. *
Required
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