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Opening Hours : Mon-Sat 9:00-20:00
USA/CAN :
info@regenamex.com
Opening Hours : Mon-Sat 9:00-20:00
info@regenamex.com
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Fly & Buy Journey Program
Treatments
Neurological Diseases
Hormonal Disorders
Musculoskeletal Disorders
Respiratory Diseases
Cardiovascular Diseases
About
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Home
Fly & Buy Journey Program
Treatments
Neurological Diseases
Hormonal Disorders
Musculoskeletal Disorders
Respiratory Diseases
Cardiovascular Diseases
About
Contact
Medical History
First Name
Middle Name
Last Name
Day of Birth
Weight in kilograms
Email
Phone Number
MEDICAL QUESTIONNAIRE
What services are you interesting in:
Stem Cells
HGHRT
TRT
Explain the most concerning issues about your health?
What kind of symptoms do you have?
Have you had a consultation with a Regenamex doctor?
Yes
No
If your answer was yes, what was the out come for your diagnosis/protocols, who was the doctor helping you?
Please list all medical conditions you have, past and present:
Please list all medications and the current dosage that you taking:
Alergies?
*
Yes
No
If you answer yes to alergies, which ones?
Surgeries?
*
Yes
No
If you answer yes to surgeries, which ones?
Smoking?
Yes
No
Alcoholism?
Yes
No
Do you have high blood pressure?
Yes
No
Please give us a detailed description of all the Symptoms that go along with your muscle skeletal issues
Upload Files like Xrays no more than 15MB and no more than 6 files at a time
Submit Medical reports
Do you have accommodations?
Yes
No
If the answer was yes, where are you staying? - If your answer was no, we have all inclusive experience in our package! share your dates:
If you have confirmation of your flight, send us your itinerary:
What are your potential ideal bookings dates for your trip to wellness?
How did you hear about us?
Social Media
Youtube
Google
Friend
Other
If you answer above was Friend, what is his/her name?
Who was your patience advisor?
Send