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Patient InTake Form

Your goals, it terms of top three health areas you would like to experience improvements in?*

How long have you had this medical condition?

Have you ever received stem cell treatments in the past?*

Are you willing to travel to Bogota, Colombia to receive stem cell treatment in our state of the art medical clinic?*

Are you aware that stem cell treatments are not covered by insurance?*

Please confirm that you have read and agree to Stemwell's Terms of Service and Privacy Policy*