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Got Stem Cells? Patient Screening Application

Please complete this brief online screening application to find out if you are a candidate for our treatment protocol

Between the age of 18-80? *

Yes

No

Pregnant? *

Yes

No

Cancer diagnosis? *

Yes

No

Active or chronic viral infection? *

Yes

No

Please include a brief description of what you hope to achieve with treatment. This will help our medical team better understand your unique goals.

First Name *

Last Name *

Phone *

Email *

Gender *

Male

Female

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email: optimizeyourlife@infinityhealth.zone

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