This is a patient funded treatment and unfortunately cannot be covered by any insurance providers, which will require the patient to pay for the cost of the treatment. The cost will vary depending on the type of treatment, patient’s condition(s) and delivery method needed.
I am able and willing to travel to StemCells21 Thailand to receive treatment
Which of the following conditions are you currently being treated or have been treated for in the past (please check the appropriate boxes):
Has any member of your family had any of the following illnesses? If yes, please place an
“X” in the appropriate boxes to identify all illnesses/conditions of your blood relatives.
Do you currently have any of the following symptoms? Please check all appropriate boxes:
*You will automatically receive an Email copy of this form for safe keeping.