Stem Cell Therapy Patient Application

StemFinityCord, Malaysia provides stem cell therapy under approved clinical protocols for subjects with conditions including Autism, Cerebral Palsy, Degenerative Joint Disease, Heart Failure, Multiple Sclerosis, Osteoarthritis, Rheumatoid Arthritis, Spinal Cord Injury and more. We do not treat Cancer.

Please fill out the application below and submit to us online. Should you encounter any challenges, please use 'Contact Widget' in the right bottom corner.

NOTE: Procedures are not covered by most insurance and will require travel to Malaysia. Our fees start at MYR35,000 / USD8,000 

Patient Application

  • Where you referred by someone? Did you find us online?
  • Patient's Personal Information

  • Upon review of your case we will provide feedback to your email. Please provide your single best email address.
  • 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.
  • Date Format: DD slash MM slash YYYY
  • Patient's Physical Limitations

  • If patient has got any other special needs, please describe them
  • Patient's Diagnosis / Health Condition

  • Please describe the reason you are considering stem cell treatment.
  • Please describe your primary diagnosis and provide a brief description of symptoms.
  • Date Format: DD slash MM slash YYYY
  • Please list the medications you are on at the moment
  • Subject History: Cancer

  • Subject History: Diabetes

  • Are you taking insulin? Anything else we should know on this matter?
  • Subject History: Neurological System

  • Please tick what's applicable to your condition
  • Subject History: Pulmonary System

  • Subject History: Cardiovascular Problems

  • Subject History: Circulatory

  • Subject History: Gastrointestinal Problems

  • Subject History: Upper Respiratory Test

  • Subject History: Rheumatic Screen

  • Subject History: Endocrinological System

  • Subject History: Allergy

  • Subject History: Other

  • Do You Take Human Growth Hormone? How Long Have You Taken Growth Hormone? How Many Growth Hormone Injections per Week?
  • If you have done PSA test, please let us know the date and PSA test result.
  • If you have done Mammograms, please let us know the date and the test result.
  • Surgical / Hospitalizations

  • Please provide as much information about your surgical procedures as possible (name and date of the procedure etc).
  • Family History

  • By clicking “Submit” I attest that I have read the Patient Application Disclaimer and 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.
    Processing may take up to a minute. A new web page will load to confirm receipt of your application. After you click the Submit button, please do not reload this page or click your browser’s back button.
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