Patient
Screening
Application

Please complete this brief online application to find out if you are a candidate for our IRB-approved stem cell protocol located in Grand Cayman.

It is highly recommended that you review our FAQ Page before continuing.

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Initial Screening

The initial screening form will allow us to determine if you are a good candidate to begin the pre-treatment process. Most applications will receive a response within 72 hours.

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Intake Forms

If accepted you will receive a link to complete your medical history forms. Once completed you will receive a list of labs / exams that must be completed prior to treatment.

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Packet Review

Once your forms, medical history, and labs / exams have been submitted for review, our medical team may provide final clearance.

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Schedule Treatment

Once approved, you may book your treatment on your desired date, subject to availability.

It is highly recommended that patients review our FAQ Page before continuing.

Please answer the following screening questions to determine if you are a candidate to begin the pre-treatment process for our stem cell program.

COVID-19 Update: Our ports of entry are currently closed for international travel. We are still accepting patient applications for future treatment dates, and our medical team is still processing incoming patient pre-treatment packages. Once a patient has completed their pre-treatment requirements, they will be put on a contact list to schedule a treatment date at earliest availability.

Form completion time: under 3 minutes.

Step 1

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Begin application

This is a patient-funded program

I understand that this is a patient-funded program and treatment cost is $25,000 USD. Travel and accommodation are not included. (Financing available for US residents)

Yes

Step 2

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Please acknowledge the above statement in order to continue.

Please select at least one option.

Between the age of 18-80?

Applicant must be between the age of 18-80 in order to be eligible for treatment at DVC Stem.

Yes

Step 3

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Applicant must be over the age of 18 in order to be eligible for treatment at DVC Stem.

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 to our clinic for treatment.

Yes

Step 4

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Our clinic is located in Grand Cayman. Patient must be able to travel internationally.

Please select at least one option.

Pregnant?

Is the candidate pregnant or at risk of being so?

Yes

Step 5

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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

Yes

Step 6

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Please select at least one option.

Cancer diagnosis?

Is candidate currently diagnosed with any type of cancer?

Yes

Step 7

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Any active cancers will disqualify patient for treatment.

Please select at least one option.

Active or chronic viral infection?

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

Yes

Step 8

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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 9

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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 10

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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 11

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Please complete the field above.

Candidate information

Please include full name, age and gender.

First Name

Last Name

Age

Gender

MaleFemale

Step 12

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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

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Who referred you to DVC Stem?

Email Address

PatientScreeningApplication

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Success!

Patient
Screening
Application