Are you a candidate
for stem cell therapy?

Please answer the following screening questions to determine if you  are a candidate for our program.

If you have any questions regarding our practices or protocols prior to completing your application, please visit our
FAQ page.

Form completion time: under 3 minutes.

Step 1
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This is a patient-funded program

I understand that this is a patient-funded program and costs start at $17,500 USD, depending on condition. Travel and lodging are not included. (Financing available)

Step 2
2 / 12
Please acknowledge the above statement in order to continue.
Next
Please select at least one option.
Capable of international travel?

DVC Stem is located in Grand Cayman. Candidate must be physically, mentally and legally able to travel internationally for treatment.

Step 3
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Our clinic is located in Grand Cayman. Patient must be able to travel internationally.
Next
Please select at least one option.
Pregnant?

Is the candidate pregnant or at risk of being so?

Step 4
4 / 12
Please select at least one option.
Taking immunosuppressives?

This includes but not limited to: Calcineurin Inhibitors: Tacrolimus and Cyclosporine Antiproliferative agents: Mycophenolate Mofetil, Mycophenolate Sodium and Azathioprine

Step 5
5 / 12
Please select at least one option.
Cancer diagnosis?

Is candidate currently diagnosed with any type of cancer?

Step 6
6 / 12
Any active cancers will disqualify patient for treatment.
Next
Please select at least one option.
Active or chronic viral infection?

This includes HIV1, HIV2, Hepatitis B or Hepatitis C.

Step 7
7 / 12
Please select at least one option.
Current medical condition

We specialize in treatments for Autoimmune conditions & Chronic Inflammation.  We do not provide localized site injections.

Medical Condition (required)
Current Diagnosis
Step 8
8 / 12
Please complete the fields above.
Medical history

Please describe your current symptoms and medical history. Providing detailed information will help speed up the application proccess.

Current symptoms / medical history
Step 9
9 / 12
Please complete the field above.
Treatment goals

Please include a brief description of what you hope to achieve with treatment. This will help our medical team better understand your unique goals.

What are your treatment goals?
Step 10
10 / 12
Please complete the field above.
Candidate information

Please include full name, age and gender.

Full name
Age
Gender
Step 11
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Please complete all fields above.
Contact information

Thanks for taking the time to complete this application. There are no obligations associated with completing this application.

Final Step
12 / 12
Email Address

Application received

You are now one step closer to a better quality of life. Our Medical Director will review your application and respond with either an approval to continue or a request for further information.

Want to see our world class treatment protocol?Click Here
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