Treatment Information Request Form

Welcome to our Patient Treatment Information Request form. Please fill out all the information below and click the "Submit Request" button. An RSCI representative will contact you shortly to discuss your treatment options.

For a list of conditions successfully treated with Repair Stem Cells, scroll through Disease drop down in the form below. If your disease is not listed choose Disease Not Listed and include your disease in Message box.

Our patient support program is free of charge. We are paid by the hospitals – and since we work with a large group of providers, we are not ‘selling’ any specific center. Our mission is to educate you so you will know enough to make your own decisions about stem cell therapy.

 

Treatment Information Request

RSCI respects your privacy and does not sell or distribute your information to third parties.

 We are processing your treatment request. Please wait...

Patient Information

First Name:			Last Name:
Country:	Select... Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia-Herzegovinia Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo (Dem. Republic) Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey and Alderney Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Island of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea (Democratic Republic of) Korea (Republic of) Kosovo Kuwait Kyrgyz Republic Laos Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldavia Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua-New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Re union Republic of Dominica Romania Russia Russian Federation Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Vatican (Holy See) Venezuela Vietnam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Zambia Zimbabwe
City:			State/Province:
Year of Birth:	Select... 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
Primary Disease:	Please select a disease... Absence Of The Septum Pellucidum Acquired Ataxia Acquired Epileptiform Aphasia Acute Disseminated Encephalomyelitis ADD/ADHD Agenesis Of The Corpus Callosum Alcardi Syndrome ALS Alzheimer's Amyotrophic Lateral Sclerosis Anti-Aging Arthritis/Joint Diseases Ataxia Autism Autoimmune Diseases Batten Disease Becker's Muscular Dystrophy Bell's Palsy Bird/Farmer's Lung Bone Fractures Brachial Plexus Birth Injuries Brachial Plexus Injury Brain Conditions/Diseases Brain Injury Breast Enhancement/Repair Brown-Sequard Syndrome Bulbospinal Muscular Atrophy Cancer Carpal Tunnel Syndrome Cartilage Central Cord Syndrome Central Pain Syndrome Central Pontine Myelinolysis Cerebellar Ataxia Includes Type 6 Cerebellar Hypoplasia Cerebral Atrophy Cerebral Hypoxia Cerebral Palsy Chiari Malformation Chronic Inflammatory Demyelinating Polyneuropathy Chronic Obstructive Pulmonary Disease Chronic Renal Failure Cirrhosis Congenital Myopathy COPD Cosmetic Criticcal Limb Ischemia Crohn's Disease Damage To The Optic Nerve Deficiency Syndromes Degenerative Disc Disease Dementia Diabetes Type 1 Diabetes Type 2 Diabetic Foot Duchenne Muscular Dystrophy Early Infantile Epileptic Encephalopathy Early Stage Ataxia Telangiectasia Emphysema Encephalitis Encephalopathy Epilepsy Erectile Dysfunction Erythematosis Facial Rejuvenation Fanconi's Anemia Femoral Head Necrosis Fibromyalgia Friedreich Ataxia Gaucher's Disease Glaucoma Glucose Transfer Disorders Glycogen Storage Disease Type II Guillain-Barr Syndrome Heart Disease Hepatic Cirrhosis Hepatitus C Hereditary Ataxias Hodgkin's Disease Huntington's Disease Hyoersensitivity Pneumonitis Hypertonia Hypotonia Including Type C Infantile Osteopetrosis Infantile Spasms Inflammatory Bowel Diseases Interstitial Lung Disease Ischemic Optic Neuropathy Kennedy's Disease Kidney Disease Lack Of Cardiac Mobility Landau-Kleffner Syndrome Leber's Hereditary Optic Neuropathy Leukemia Leukemia Lissencephaly Liver Lissencephaly Liver Disease Lower Limb Ischemia Lung Disease Lupus Lyme Disease Lymphoma Machado-Joseph Disease Macular Degeneration-Dry Macular Degeneration-Wet MDS Meningitis Microcephaly Motor Neuron Disease Multiple Myeloma Multiple Sclerosis Multisystem Atrophy Muscular Dystrophy Myasenthia Gravis Myelodysplastic Syndrome Myoclonic Encephalopathy Of Infants Myoclonus Myopathies Neurofibromatosis Neurological - Other Neuronal Ceroid Lipofuscinosis Neurotoxicity Non Hemorragic Brain Vascular Accident Non Hodgkin's Lymphoma Ohtahara Syndrome Olivopontocerebellar Atrophy Optic Atrophy Optic Nerve Damage Optic Nerve Disorders Optic Nerve Hypoplasia Osteoarthritis Osteogenesis Imperfecta Osteonecrosis Parkinson's Peripheral Artery Disease Peripheral Nerve Injuries Peripheral Vascular Disease Perisylvian Polymicrogyria Pompe Disease Post Polio Syndrome Primary Lateral Sclerosis Progressive Muscular Dystrophy Psoriatic Arthritis Pulmonary Fibrosis Pulmonary Hypertension Renal Failure Restrictive Lung Function Retinitis Pigmentosa Retinopathy of Prematurity Rett Syndrome Rheumatoid Arthritis Sarcoidosis Scaphoid Nonunion Schizencephaly SCI SCID Septo-Optic Dysplasia Sequelae Severe Aplastic Anemia Severe Combined Immune Deficiency Sickle Cell Anemia Spastic Tetraparesis Spina Bifida Spinal Amiotrophy Spinal Cord Injury Spinal Muscular Atrophy Spinocerebellar Ataxia Spinocerebellar Atrophy Spinocerebellar Degeneration Stroke Systemic Lupus Erythematosus Tendonitis Thalassemia Transverse Myelitis Traumatic Brain Injury Ulcerative Colitis Vascular Diseases Venous Multiple Sclerossis (CCVI) West Nile Virus West Syndrome X-Linked Spinal And Bulbar Muscular Atrophy --------------------------- Disease Not Listed
	*Note: If you have a neurological condition that is not listed select Neurological-other or if you do not find your disease in the list, select Disease Not Listed, and add the disease to the message area.
Year Diagnosed:	Select... 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
Secondary diseases to treat – if any list them in this box:

Attention

Contact Information

If Different Than Patient’s Name Above, Your Name (otherwise leave blank and skip to Primary Phone question below):
First Name:			Last Name:
Relation to Patient:	Select.. Self Parent Other Relative Friend Doctor NotListed
Primary Phone:			Alt. Phone:
Best Time to Call:	AnytimeMorningAfternoonEvening
Email:
Confirm Email:

Message:

Please review and check that you have read the following:

Applicable medical records will need to be sent to the treatment facility and treating doctor
Treatment costs range from $12,000 to $20,000 USD
     Note: Can be more for complicated procedures.
Insurance will not cover treatment cost, and all centers require full payment in advance of treatment.

Attention

Important: Please click the "Submit Request" button one time. Double-clicking will submit a duplicate request. If you are the contact person for more than 1 patient, please use a seperate email for address for each patient. (We use email address as a key in our system)