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Patient Application

The Riordan Center provides stem cell therapy for subjects with conditions including Autism, Cerebral Palsy, Degenerative Joint Disease, Heart Failure, Multiple Sclerosis, Osteoarthritis, Rheumatoid Arthritis, Spinal Cord Injury, and Sports Injuries.

Please fill out the application below and submit to us online.

If you cannot complete this online application and need a paper form, please call us at 1-800-980-STEM (7836) to request an application in MS Word format.
These procedures are not covered by most insurance and will require travel outside the US and Canada.

Treatments include from 3 to 8 separate stem cell infusions/injections over the course of 3 to10 working days depending upon the protocol employed. A fee will be quoted once your treatment protocol has been determined.

Fee includes: Treatment protocol, airport VIP customs clearance, airport transportation, Hilton Hotel room, breakfast and WiFi.

We DO NOT treat:
ALS
Duchenne’s Muscular Dystrophy
Si desea llenar nuestra aplicación en español, por favor acceda a este vínculo.

Aplicación en Español

IMPORTANT: To best ensure patient safety, we DO NOT treat anyone with active cancer or a history of cancer in the past 5 years.

Personal Information
Clinic Location : Panama
Were you referred?
Referred by whom? How did you first learn
about us?*		 Select
Salutation* : Select
Legal First Name (as on license or passport)* :
Legal Middle Name (as on license or passport) :
Legal Last Name (as on license or passport)* :
Date of Birth* : Month Day Year
Weight (pounds)* :
Height* : Feet Inches
Gender* : Select
Address* :
City* :
State or Province :
Zip or Country Code:
Country* : Select
Time Zone* : Select

 

One of our physicians might need to speak with you (or the applicant’s representative) personally. Please list the single best phone number to reach you, Monday – Friday 10 AM – 7PM, Central Standard Time (international, GMT – 6).

Best Phone* : (include area code)
Work Phone : (include area code)
Cell Phone : (include area code)
FAX Number: (include area code)
Email* :
Occupation:
Marital Status*: Select

Parent/Guardian Information
Name :
Address :
Home Phone : (include area code)
Office Phone: (include area code)
Cell Phone: (include area code)
Alternate Phone: (include area code)

Physical Limitations
*Need Assistance Walking? Yes No
*Wheel Chair Needed? Yes No
Other Needs :

Emergency Contact
Name* :
Relationship* :
Phone* : (include area code)
Address:
City:
State or Province:
Zip or Country Code:
Country:

Primary Diagnosis/Disease
Physician Name* :
Physician Phone: (include area code)
Primary Disease Diagnosis* : Select
Primary Symptoms/Medical Conditions:* :
Date of Diagnosis* : Month Day Year
Medical Records Available?
Current Medications:
Anticoagulated?
Anticoagulated Since When: Month Day Year
Why Anticoagulated?

Subject History: Cancer
*Have you ever been diagnosed with any type of cancer? Yes No
Cancer Type:
Date Cancer Diagnosed: Month Day Year
Cancer Status:

Subject History: Diabetes
Are You Diabetic?
Taking Insulin?

Subject History: Neurological System
Vision Decrease?
Vision Black Spots?
Vision Nistagmus?
Muscle Weakness?
Muscle Wasting?
Walking Difficulties?
Decreased Hand Strength?
Fainting?
Speech Problems?
Tingling Sensation?
Muscle Fasciculations?
Spasticity?
Hyperreflexia?
Hyporeflexia?
Depression?
Loss of Memory?
Headaches?
Sleep Disturbances?
Dizziness?

Subject History: Pulmonary System
Asthma?
Chronic Bronchitis?
Chronic Cough?
Emphysema?
Tuberculosis?

Subject History: Cardiovascular Problems
Myocardial Infarction?
Myocardial Infarction Date: Month Day Year
Angina Pectoris?
Tachycardia?
By-Pass Surgery?
By-Pass Surgery Date: Month Day Year
Hypertension (high blood pressure)?
Hypotension (low blood pressure)?

Subject History: Circulatory
Poor Arterial Circulation?
Poor Venous Circulation?
Leg Cramps?
Tired Legs?
Swollen Ankles?
Varicose Veins?
Tingling Sensation in Arms and Legs?
Falling Asleep of the Hands and Legs?
*Ulcers or open wounds anywhere on your body? Yes No

Subject History: Gastrointestinal Problems
Acid Indigestion?
Bloating?
Stomach or Duodenal Ulcer?
Stomach or Duodenal Ulcer Date: Month Day Year
Loss of Appetite?
Rapid Weight Gain?
Rapid Weight Loss?
Overweight Problem?
Have You Had Upper GI endoscopy?
Upper GI Date: Month Day Year
Upper GI Results:
Hepatitis?
Hepatitis Type:
Gall Bladder Problems?
Gall Stones?
Icterus?
Recurring Diarrhea?

Subject History: Upper Respiratory Test
*Chronic Sinusitis? Yes No
*Allergic Sinus Problem? Yes No
*Chronic Allergic Rhinitis? Yes No
*Sinus Headaches? Yes No
*Chronic Nose Bleeds? Yes No
*Chronic Colds? Yes No

Subject History: Rheumatic Screen
Soft Tissue Rheumatism?
Articular Rheumatism?
Joint Pain?
Back Pain?
Rheumatoid Arthritis?
Other Rheumatic Conditions:

Subject History: Endocrinological System
Diabetes Mellitus?
Overactive Thyroid?
Underactive Thyroid?
Adrenal Gland Dysfunction?
Female Menopause?
Male Menopause?
Other Endocrinological Conditions:

Health History Allergy:
*Food Allergy, Especially Eggs? Yes No
*Hay Fever? Yes No
*Allergic Asthma? Yes No
*Medication Allergies? Yes No
Medication Allergy Symptoms:
*Allergies to any vaccinations? Yes No

Subject History: Other
When was your last vaccination? Month Day Year
*Do You Smoke Cigarettes? Yes No
*Do You Smoke Cigars? Yes No
*Do You Smoke Pipes? Yes No
How Much Do You Smoke Per Day?
*Do you drink wine? Yes No
*Do you drink beer? Yes No
*Do you drink hard liquor? Yes No
How much do you typically drink per day?
*Please list any nutritional supplements you are taking:
*Other Significant or Chronic Illnesses :
Do You Take Human Growth Hormone?
How Long Have You Taken Growth Hormone?
Human Growth Hormone Injections per Week:
PSA Test (Men Only)?
PSA Test Date: Month Day Year
PSA Test Result:
Periodic Mammograms

(Women only)?
Mammogram Test Date: Month Day Year
Mammogram test result:

Surgical/Hospitalizations
Surgical Procedure 1:
Surgical Procedure 1 Date: Month Day Year
Surgical Procedure 2:
Surgical Procedure 2 Date: Month Day Year
Surgical Procedure 3:
Surgical Procedure 3 Date: Month Day Year
Other Surgical Procedures:

Family History
Has any member of your family had any of the following:
Hypoglycemia?
Diabetes?
Thyroid Problem?
Hormone Problem?
Cancer?
High Blood Pressure?
Kidney Problem?
Heart Problem?
Leukemia?
Arthritis?
Prostate Problem?
Mental Disorder?
Anxiety?
Lung Problem?
Fatigue?
Stroke?
Do you have any questions or comments?:

By clicking “Submit”:

  • I attest that all information I have provided on this form is accurate and complete.
  • I understand that inaccurate or incomplete information may result in denial of treatment.
  • I confirm that I have read and understand the following information:
    • The science of treatment with adult stem cells is in its infancy.
    • The treatments described on cellmedicine.com have not been evaluated by the US FDA and are not considered to be standard of care for any condition or disease.
    • There could be significant and unknown risks associated with adult stem cell treatments, as long-term studies have not been performed.
    • For most diseases no prospective, randomized clinical trials of adult stem cells have been performed, therefore no guarantee of safety or effectiveness is made or implied.
    • Treatments by licensed doctors will only be performed after the patient understands and agrees to informed consent.
    • The results of testimonials of people who appear on this website who have undergone stem cell treatment are not necessarily typical.
    • Processing may take up to a minute.
    • A new web page will load to confirm receipt of your application.
    • Applications take up to 5 working days to review from the first working day they are received.
    • After you click the Submit button, please do not reload this page or click your browser’s back button.