How Did You Hear About StemGenex? --None-- News article Word-of-mouth referral from friend Online search (e.g., Google, Yahoo, Bing) Online forum/discussion board Social media (e.g., Facebook, Twitter) Other (please specify) On a Scale of 1-10, With 10 Being The Highest, Please Rate Your Pain Level? --None-- 1 2 3 4 5 6 7 8 9 10 Does Anything Concern You About Receiving Stem Cell Treatment?

What Are Your Concerns?

What Symptoms Would You Like To See Improved With This Treatment?

As a world leader in stem cell therapy and research, StemGenex® provides patients access to cutting-edge stem cell therapy utilizing the most advanced clinical protocols. Safety and efficacy are the primary focus of these treatments which are performed by board certified physicians including advanced scientific protocols under the direction of our Ph.D. research scientist.

• Please be aware of the following important disclosures:
• The science of treatment using adult stem cells is in its initial stages.
• The treatments described on www.StemGenex.com are not approved by the US FDA and are not currently considered to be standard of care for any condition or disease.
• There could be significant and unknown risks associated with adult stem cell treatments, as long-term studies have not been performed.
• As with all medical procedures, stem cell therapy through StemGenex does not provide or imply a guarantee of safety or effectiveness.
• Treatments by licensed doctors will only be performed after the patient understands and agrees to informed consent.

By selecting "Yes", you agree that you have read and understand all of the statements above. I certify that my complete medical history is disclosed on this form including but not limited to a diagnosis, all surgeries, medications, hospitalizations and allergies. I understand omitting information may disqualify me as a candidate for treatment.