Online Medical Form

Please fill out the online medical form, and our doctors will review it within 48 hours.

Your designated patient representative will be in touch regarding the next steps.

Patient Representative

Patient Representative(Required)

Patient Information

Patient Name(Required)

Patient Phone(Required)

Patient Email(Required)

Address

Date of Birth

Patient's Height

Patient's Weight

Patient's Gender

Male

Female

Patient's first language

Patient's second language

Contact Person Information (if different from patient)

Contact Person's Name

Contact Person's Email

Contact Person's Phone Number

Medical Conditions & History

Primary Diagnosed Condition (Ex. C6 Spinal Cord Injury)

Date of Diagnosis

Current Symptoms

Treatment History (Please include past & present treatments, medications, and rehabilitation programs used in treating your primary condition.)

Secondary Diagnosed Condition (Ex. Diabetes)

Additional Diagnosed Conditions and/or Relevant Family Medical History

Past Surgeries for Any of Your Conditions

Medical Questions

Please answer the questions about the patient's condition in as much detail as possible. Every question requires an answer, so if you are unsure please just choose "Unsure".

Does the patient have any communicable illnesses such as HIV, Hepatitis, Tuberculosis (TB), Herpes, or any other sexually transmitted diseases?

Yes

No

Unsure

Does the patient have, or has the patient ever had, a malignant or benign cancerous tumor?

Yes

No

Unsure

Does the patient have hypertension (high blood pressure) or hypotension (low blood pressure)?

Yes

No

Unsure

Does the patient currently have any bedsores?

Yes

No

Unsure

Does the patient currently have any ulcers?

Yes

No

Unsure

Does the patient have shortness of breath or difficulty breathing?

Yes

No

Unsure

Does the patient currently require the use of a ventilator?

Yes

No

Unsure

Has the patient undergone a tracheotomy?

Yes

No

Unsure

Does the patient require suctioning to keep their airways clear?

Yes

No

Unsure

Does the patient require the use of supplemental oxygen?

Yes

No

Unsure

Does the patient have any metal plates or rods in their body?

Yes

No

Unsure

Does the patient have a pacemaker?

Yes

No

Unsure

If yes, please explain why and what type.

Does the patient have a continuous-medication pump?

Yes

No

Unsure

Does the patient have a feeding tube?

Yes

No

Unsure

Has the patient received at least one vaccination in the past three months?

Yes

No

Unsure

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File Doctor’s Reports

Please attach any doctor’s reports, medical test results, and discharge summaries that pertain to the patient’s Medical Conditions & History.PLEASE NOTE: Large files may require extra time to upload, so after you’ve clicked “SUBMIT” below, please do not close your browser window until you’ve received the message confirming a successful submission.

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File Upload

Drop files here or

Accepted file types: jpeg, jpg, gif, png, pdf, rar, zip, iso, Max. file size: 1,000 MB.

Please describe the type of results the patient is hoping to achieve with this treatment.

How did the patient find out about this treatment?

If accepted to the program, on what date would the patient like to start their treatment?