Apply for treatment

We kindly ask that you complete this brief application so that our medical team will be able to determine your candidacy for treatment.

Therapy can be highly effective for chronic inflammation, autoimmune conditions, degenerative conditions, and general wear and tear.

Form completion time: under 5 minutes

Step 1
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Capable of international travel?

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

Step 2
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Please select at least one option.
Pregnant?

Is the candidate pregnant or at risk of being so?

Step 3
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Please select at least one option.
Taking immunosuppressive drugs?

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

Step 4
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Please select at least one option.
Cancer diagnosis?

Is candidate currently diagnosed with any type of cancer?

Step 5
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Please select at least one option.
Active or chronic infection?

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

Step 6
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Please select at least one option.
Current medical condition

Please choose a category that best represents your current condition. If applicable please also indicate your current medical diagnosis.

Medical Condition (required)
Current Diagnosis
Year of Diagnosis (optional)
Step 7
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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 8
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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 9
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Please complete the field above.
Candidate information

Please include full name, age and gender.

Full name
Age
Gender
Step 10
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Please complete all fields above.
Contact information

Thanks for taking the time to complete this application. Please enter your email below, so our medical team can respond to your application. There are no obligations associated with completing this application.

Step 11
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Were you referred by someone?
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.

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