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Welcome to the StemGenex Medical History Form

This medical history survey is used to determine a patient’s candidacy for safe and effective stem cell therapy through StemGenex Stem Cell Research Centre. Please fill out as many questions as possible so we can determine if our stem cell clinic is right for you.


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 scientific protocols set forth by our PhD neuroscientist. Please be aware of the following important disclosures being made:

  • The science of treatment using adult stem cells is in its initial stages.
  • The treatments described on 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 checking this box you agree that you have read and understand all of the statements above.
By checking the box below 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.

StemGenex® takes great pride in our response time to your inquiry and providing you with the highest level of service possible. You should expect to hear back shortly from your patient advocate to confirm that we have received your application form. Please list the single best phone number to reach you, Monday-Friday 8am-6pm Pacific Standard Time (PST).