Medical Record

Complete Your Medical Record

Share your medical history so our specialists can prepare a treatment plan tailored to your condition.

The Stem Cells Institute Transplant Medical Record

Patient Information

First Name *

Last Name *

Email Address *

Patient Gender *

Preferred Language *

Age *

Height *

Weight *

Guardian’s Name *

Phone / WhatsApp *

Condition(s)

Condition / Treatment Interest *

Current Medications *

Allergies to Medications or Foods

Primary conditions for which you are seeking treatment

Non Pathological History

Do you Smoke? *

Do you Drink? *

Surgical History

Surgery Date

Surgery- Procedure or Hospitalization

2nd Surgery Date

2nd Surgery- Procedure or Hospitalization

3rd Surgery Date

3rd Surgery- Procedure or Hospitalization

Medical Test Results

Please add all relevant information from your condition *

Blood works, MRI, X-Rays, other relevant medical tests PDF, DOC/DOCX, JPG/JPEG, PNG

Medical Record Received

Thank you. Your medical history and test documents have been securely transmitted to our medical board in Guanacaste, Costa Rica. Our specialists will review your records and reach out within 24 hours.