Stem Cell Treatment Patient Application

Patient Application Disclaimer

Stem Cell Institute, Panama provides stem cell therapy under IRB-approved clinical protocols for subjects with conditions including Autism, Cerebral Palsy, Degenerative Joint Disease, Heart Failure, Multiple Sclerosis, Osteoarthritis, Rheumatoid Arthritis, Spinal Cord Injury, and Sports Injuries.

Please fill out the application below and submit to us online.

 If you cannot complete this online application and need a paper form, please call us at 1-800-980-STEM (7836) to request an application in MS Word format.

These procedures are not covered by most insurance and will require travel outside the US and Canada.

We DO NOT treat:

  • ALS
  • Duchenne’s Muscular Dystrophy

Patient application

"*" indicates required fields

Were you referred?
Date of Birth*
One of our physicians might need to speak with you (or the applicant’s representative) personally. Please list the single best phone number to reach you, Monday – Friday 10 AM – 7PM, Central Standard Time (international, GMT – 6).
Need Assistance Walking?*
Wheel Chair Needed?*
Date of Diagnosis*
Medical Records Available?
Anticoagulated Since When
Have you ever been diagnosed with any type of cancer?*
Date Cancer Diagnosed
Are You Diabetic?
Taking Insulin?
Vision Decrease?
Vision Black Spots?
Vision Nistagmus?
Muscle Weakness?
Muscle Wasting?
Walking Difficulties?
Decreased Hand Strength?
Speech Problems?
Tingling Sensation?
Muscle Fasciculations?
Loss of Memory?
Sleep Disturbances?
Chronic Bronchitis?
Chronic Cough?
Myocardial Infarction?
Myocardial Infarction Date
Angina Pectoris?
By-Pass Surgery?
By-Pass Surgery Date
Hypertension (high blood pressure)?
Hypotension (low blood pressure)?
Poor Arterial Circulation?
Poor Venous Circulation?
Leg Cramps?
Tired Legs?
Swollen Ankles?
Varicose Veins?
Tingling Sensation in Arms and Legs?
Falling Asleep of the Hands and Legs?
Ulcers or open wounds anywhere on your body?
Acid Indigestion?
Stomach or Duodenal Ulcer?
Stomach or Duodenal Ulcer Date
Loss of Appetite?
Rapid Weight Gain?
Rapid Weight Loss?
Overweight Problem?
Have You Had Upper GI endoscopy?
Upper GI Date
Gall Bladder Problems?
Gall Stones?
Recurring Diarrhea?
Chronic Sinusitis?*
Allergic Sinus Problem?*
Chronic Allergic Rhinitis?*
Sinus Headaches?*
Chronic Nose Bleeds?*
Chronic Colds?*
Soft Tissue Rheumatism?
Articular Rheumatism?
Joint Pain?
Back Pain?
Rheumatoid Arthritis?
Diabetes Mellitus?
Overactive Thyroid?
Underactive Thyroid?
Adrenal Gland Dysfunction?
Female Menopause?
Male Menopause?
Food Allergy, Especially Eggs?*
Hay Fever?*
Allergic Asthma?*
Medication Allergies?*
Allergies to any vaccinations?*
When was your last vaccination?
Do You Smoke Cigarettes?*
Do You Smoke Cigars?*
Do You Smoke Pipes?*
Do you drink wine?*
Do you drink beer?*
Do you drink hard liquor?*
Do You Take Human Growth Hormone?
PSA Test (Men Only)?
PSA Test Date
Periodic Mammograms (Women only)?
Mammogram Test Date
Surgical Procedure 1 Date
Surgical Procedure 2 Date
Surgical Procedure 3 Date
Has any member of your family had any of the following:
Thyroid Problem?
Hormone Problem?
High Blood Pressure?
Kidney Problem?
Heart Problem?
Prostate Problem?
Mental Disorder?
Lung Problem?
  1. By clicking “Submit” I attest that all information I have provided on this form is accurate and complete.
  2. I understand that inaccurate or incomplete information may result in denial of treatment. Processing may take up to a minute.
  3. A new web page will load to confirm receipt of your application.
  4. After you click the Submit button, please do not reload this page or click your browser’s back button.


Questions? We’re here to help.

We manufacture the cells in a controlled environment that is optimized for generating a final product with high anti-inflammatory properties. During the manufacturing process we supercharge the stem cells by training them to survive harsh environments often found in diseased or damaged tissues. CPI doesn’t use any type of stem cell; we have highly specialized stem cells that have increased therapeutic properties over other stem cells.

Using our in-house manufacturing facility, we are able to generate billions of cells that are highly therapeutic and targeted to areas suffering from an acute or chronic inflammatory condition.

Current stem cell treatments in the United States are being performed under FDA approved clinical trials, and although the data is very encouraging, final FDA approval for many of these treatments is still years away. SCRI is regulated by national regulatory agencies, COFEPRIS or the Federal Committee for Protection from Sanitary Risks (Comisión Federal para la Protección contra Riesgos Sanitarios) is the equivalent of the FDA in Mexico. SCRI is approved by COFEPRIS to perform cell therapy that in many regions such as the United States is years away from being a treatment option.

SCRI uses protocols published in peer-reviewed medical journals that have demonstrated the therapeutic potential of cell-based intervention. Depending on the geographical location, some of these therapies may be approved or in clinical trials. We always do our best, but nothing works for everyone.

Every patient responds to therapy differently; some have very fast therapeutic benefits, while others have a more gradual long-term improvement.

Our aftercare team will continue to monitor your healing with follow-up calls. They are also available to review any exams or MRIs post-treatment with you.

The Healthier, the better: organic, low sugars, low inflammatory, No Alcohol for as long as possible before and after treatment.

Example, a patient with a healthy medical history with multiple injuries probably will not have any contraindications to being treated.

Our stem cells are isolated from umbilical cord, which is a rich source of many different cell types, including a stem cell population that SCRI has isolated. We manufacture the cells in a controlled environment that is optimized for generating a final product with high anti-inflammatory properties. Using our in-house manufacturing facility, we are able to generate billions of cells that are highly therapeutic and targeted to areas suffering from an acute or chronic inflammatory condition.

Every patient is unique and responds differently. Some patients are quick responders and experience sustained results after a single treatment, others respond gradually over time and may require additional treatments in the future to continue improving their clinical outcome. Our doctors will work with you to develop a treatment strategy for optimal results.

To determine if you qualify for stem cell therapy, our doctors will need to review your medical. Please contact our patient care team at 1 (833) 274-4442 (toll-free in the U.S.). We are happy to answer any and all of your questions.

Congrats! You’re on the path to better your life!

Stem Cell Rejuvenation Institute
Puerto Vallarta, Jalisco, Mexico

Schedule a FREE Consultation: (424) 222-8318


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