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What can be treated?

Online Candidate Application

Online stem cell application for New Zealand Stem Cell Clinic Auckland & Christchurch

If you are interested in stem cell therapy please fill out this free, no-obligation application form below to determine if stem cell therapy is suitable for you. It's important to note that stem cell therapy may not be suitable for everyone.

If you have a general enquiery please fill in the general inquirey form on our contact us page

Once submitted, your application will be automatically forwarded to us for review and Dr Beulink will carefully evaluate your medical history. This evaluation will help determine if stem cell therapy holds potential benefits for you or your condition.

Dr Beulink will thoroughly assess your application taking 3 to 5 working days and will contact you to provide feedback on your approval status. If you are approved we will guide you through the next steps, which may include a consultation.

If you cannot complete this application form online please feel free to either call us or download a version to print off, complete and mail to us (download below).

Stem cell application form.docx

Stem cell application form.docx

Online Application Form

Your date of birth

Plase select:

Mr

Mrs

Miss

Ms

Mx

Please select:

Male

Female

Other

Age

Full Name

Full contact address

Phone

Email

What is your occupation?

If retired, what was your primary occupation?

Do you have medical insurance? If so, who?

What is your primary medical condition(s) for which you are considering stem cell treatment? Please give a precise and detailed description of your diagnosis to the best of your knowledge.

Please give details of your current condition to the best of your knowledge. (eg: Have you had any tests or X-rays confirming your diagnosis? How long have you suffered this? How does this affect you? What parts of you does this affect? What is the current level of severity? What past treatments/surgery have you had for this?)

What doctors are you seeing for this condition? Eg, have you seen a specialist? What type of specialist? What prognosis (outlook/what do they say) have you been given for your condition?

What is your height?

What is your weight?

Do you carry fat around your abdomen/tummy (enough to grab with your fingers?

Are you a smoker

How many cigs. per day for how many years?

If you are an ex-smoker, how many cigs. per day were you for how many years?

When did you stop?

Please state your current alcohol intake

What is your current level of mobility?

I can easily climb 2 flights of stairs without a break.

I can climb 2 flights of stairs with a rest break.

I can walk unencumbered on a flat surface only

I can walk on a flat surface with help

I cannot walk

Do you have HIV?

Do you have Hep A, B or C?

Please state any other medical condition(s) you are currently suffering from, including approximate date of onset.

Please give a brief outline of any past and present medical conditions, or surgery including dates.

Please list all current medications you are taking, including reasons why, and dosage of each medication.

Please list all natural remedies you are currently taking, including reasons why, and dosage of each. eg; colostrum, antioxidants etc.

Please list any allergies you have, including medications, and state what reaction you have to each substance.

Have you or any family had blood or bleeding complaints, disorders or problems?

Have you ever had a surface or deep vein clot/blood clot in your leg, leg eczema, leg ulcers or a very swollen leg?

Has anyone in your family ever had a vein clot / blood clot in the leg?

Finally, where were you referred from, or where did you hear about us?

I agree there will be a cost associated with treatment. The cost for a stem cell treatment is $11,800 for a full body treatment +/- joint injection, depending on what is appropriate for you. Medical insurance, at this stage is unlikely to cover costs of this treatment.

Thanks for submitting

All information submitted will not be shared with any 3rd parties and is strictly confidential. The information will be sent directly to us and an automated reply confirming this will be sent to you.

© New Zealand Stem Cell Clinic 2011; NZ Stem Cell Clinic, Auckland, Christchurch. PO Box 36088, Merivale, Christchurch, New Zealand.

Ph/fx +64 3 3555 712, info@stemcelltreatment.co.nz

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