Simple, No-Obligation Stem Cell Therapy Questionnaire

Your Name*
First Last
Email Address*
Phone Number
Please provide if you would like to be contacted via call or text. Your information will not be shared with other entities.
I am completing this candidate assessment for:*
Your Loved One's Name*
First Last
If you are completing this assessment on behalf of a family member or friend.
I am seeking stem cell banking or therapy for:*
I am interested in:*
- Banking my stem cells for future use
- Banking my stem cells for emergency use
- Stem cell therapy for preventive & general wellness
- Stem cell therapy for condition(s)
- Stem cell therapy for symptom relief
- Stem cell therapy for rehabilitation & recovery
This field is hidden when viewing the form
I am seeking stem cell therapy for:
Other:
Are you open to traveling to Hospital Galenia in Cancun, Mexico for stem cell therapy?*
- Yes
- No
Hospital Galenia is a privately owned, state-of-the-art hospital in Cancun, Mexico where Celltex clients can receive safe, expert care from a team of regenerative medicine physicians.

Client Assessment