Please confirm your email

What is your date of birth?

This helps us calculate precise treatment dosages.

What is your biological sex?

Relevant to hormonal and dosage planning.

How do you move day to day?

Helps our team prepare your visit.

Do you know your blood type?

Helpful for planning, but not required.

Any prior diagnoses?

Select all that apply.

Infectious disease screening

Standard clinical screening. Responses are encrypted.

Prior surgeries or hospitalizations?

Include any procedure requiring anesthesia.

Family medical history?

Parents or siblings. Select all that apply.

Recent vaccination history?

Helps our team assess immune readiness.

Current medications or supplements?

Include name, dosage, and frequency if known.

Do you have any known allergies?

Select all that apply.

Mental health history?

Treated with complete confidentiality.

Current substance use

Candid answers inform protocol design. This does not affect eligibility.

Rate your daily wellbeing.

Baseline assessment — used to calibrate your protocol and measure progress post-treatment.

Have you received stem cell treatment before?

Emergency contact information

Required for medical procedures. Used only in emergencies.

Any medical documents to share?

Lab results, MRIs, X-rays, doctor's notes.