Treatment Application Please complete this brief online application to find out if you are a candidate for our stem cell protocol located in Cancun, Mexico. Response within 24 hours. No obligations. Phone Initial Screening The initial screening will allow us to determine if you are a good candidate to begin the pre-treatment process. Most applications will receive a response within 24 hours. 1. Intake Forms If accepted you will receive a link to complete your medical history forms. Once completed you will receive a list of labs / exams that must be completed prior to treatment. 2. Packet Review Once your forms, medical history, and labs / exams have been submitted for review, our medical team may provide final clearance. 3. Schedule Treatment Once approved, you may book your treatment on your desired date, subject to availability. 4. Step 2 of 12 This is a patient-funded program I understand that this is a patient-funded program and costs start at $20,000 USD. Patient-funded Program YESNO Step 3 of 12 Capable of international travel? Regenerage® Clinic is located in Cancun, Mexico. Candidate must be physically, mentally and legally able to travel internationally for treatment. Capable of international travel YESNO Step 4 of 12 Pregnant? Is the candidate pregnant or at risk of being so? Pergnant YESNO Step 5 of 12 Taking immunosuppressives? This includes but not limited to: Calcineurin Inhibitors: Tacrolimus and Cyclosporine Antiproliferative agents: Mycophenolate Mofetil, Mycophenolate Sodium and Azathioprine Taking Immunosuppressives YESNO Step 6 of 12 Cancer diagnosis? Is candidate currently diagnosed with any type of cancer? Cancer diagnosis YESNO Step 7 of 12 Active or chronic viral infection? This includes HIV1, HIV2, Hepatitis B or Hepatitis C. Active or chronic viral infection YESNO Step 8 of 12 Current medical condition We specialize in treatments for Autoimmune conditions & Chronic Inflammation. We do not provide localized site injections. Current medical condition ALS Alzheimers Cerebral Palsy Chronic Autoimmune Diseases Dementia Parkinson's Post Stroke Neurobiological therapy Advanced Anti Aging protocols Erectile Dysfunction Facial Cellular Rejuvenation HGH Joints health (Arthrosis) Penis Rejuvenation Vagina Rejuvenation Pain Stiffness Tenderness Loss of flexibility Grating sensation Bone spurs Swelling Anti-Aging Autoimmune Bronchial Asthma Cardiovascular Disease Crohn's Disease Chronic Inflammation Chronic Obtrusive Pulmonary Disease Diabetes (Type 1) Fibromyalgia Heart Failure Kidney Disease Liver Disease Lupus Lyme Disease Multiple Sclerosis Neurological Neuropathy Parkinson's Reflex Sympathetic Dystrophy Rheumatoid Arthritis Spinal Cord Injury Stroke Traumatic Brain Injury Ulcerative Colitis Other Current Diagnosis * Step 9 of 12 Medical history Please describe your current symptoms and medical history. Providing detailed information will help speed up the application proccess. Current symptoms / medical history * Step 10 of 12 Treatment goals Please include a brief description of what you hope to achieve with treatment. This will help our medical team better understand your unique goals. What are your treatment goals? Step 11 of 12 Candidate information Please include full name, age and gender. First Name * Last Name * Age Gender * Male Female Step 12 of 12 Contact information Thanks for taking the time to complete this application. There are no obligations associated with completing this application. Email Address *