New Patient Form Full Name(Required) First Name Last Name Date of Birth(Required) Month Day Year What is your age?Please enter a number from 18 to 108.What is your gender?Please SelectMaleFemaleN/AContact Number(Required)Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State / Province ZIP / Postal Code Email Address(Required) Check the conditions that apply to you or any member of your immediate relatives. Asthma Cardiac Disease Cancer Diabetes Hypertension Psychiatric Disorder Other Other Conditions Check the symptoms you are currently experiencing. Chest Pain Respiratory Cardiac Disease Cardiovascular Hematological Lymphatic Neurological Psychiatric Gastrointestinal Genitourinary Weight Gain Weight Loss Musculosketal Other Other Symptoms Medical Diagnosis (include approximate date of diagnosis).Any current symptoms of medical diagnosis listed above?List prior and current treatment and medications for medical diagnosis above.Are you currently taking any medication? Yes No MedicationsDo you have any medication allergies? Yes No Not Sure Medical AllergiesDo you use any kind of tobacco, or have you ever used them? Yes No What kind of tobacco products? How long did you use/are you using them?Family Medical HistoryAre you currently taking/using any licit or illicit drugs? Yes No What kind of drugs? How long have you used/been using them?How often do you consume alcohol? Daily Weekly Monthly Occasionally Never Are you familiar with the "Right to Try Act"? Yes No Cost of treatment ranges from $20,000-40,000. This includes pre and post treatment blood work, pre-stem cells treatment, stem cells infusion. Are you planning to pay in cash or credit? Cash Credit
