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 APPLICATION FORM

CELLMED provides stellar patient care and safe medical equipment under the highest quality GMP and biosecurity standards

Please submit the online application form below. Our medical team will assess your candidacy for stem cell treatment to get back to you.

PERSONAL INFORMATION

PHYSICAL LIMITATIONS

PRIMARY CONDITION FOR TREATMENT

MEDICAL HISTORY

Have you eve been diagnosed with any of the following? Select all that apply

LIFESTYLE & FAMILY HISTORY

Has any member of your family had any of the following? Select all that apply
Upload Document File

By clicking “Submit” I attest that:

  • All the information provided on this application form is accurate and complete.

  • Inaccurate, or incomplete information may result in denial of treatment.

  • I have read and understand the following information:

    • The science of stem cell treatment is in its infancy.

    • The treatments described and provided by CELLMED Therapy are not evaluated, or controlled by the US FDA and are not considered to be standard of care for any condition or disease. I assume any significant and unknown risks associated with the stem cell treatments provided.

    • For most diseases no prospective, randomized clinical trials of stem cells have been performed, therefore no guarantee of risk-free safety or complete effectiveness is made or implied.

    • Treatments by licensed doctors will only be performed after the patient understands and agrees to informed consent.

    • The results of testimonials of people who appear on this website who have undergone stem cell treatment are not necessarily typical.

    • If you are accepted for stem cell treatment, the treatment will be performed overseas.

    • In no event shall CELLMED Therapy, their partners, employees or any supplier of Content mentioned on this Site be liable for any losses, damages, claims, or expenses whatsoever. This includes, without limitation, direct, indirect, incidental and consequential damages, personal injury, wrongful death, lost profits, or damages resulting from lost data or business interruption, resulting from the use, misuse, or inability to use this Site or the Content, whether based on warranty, contract, tort or other legal theory, and whether or not CELLMED Therapy is advised of the possibility of such damages.

Thanks for submitting! We will contact you within 3 business days

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