0 stem cell arrival Your name Patient Intake: Arrival Date: Last Treatment Day: Departure Date: Patient Name: Preferred Nickname: Patient Email: Patient Cell Phone: Patient Date of Birth: Street 1: Street 2: City: State: Zip Code: Country: Collect Payment on arrival:YesNo Paid In Full Treatment Summary: Intake Doctor Notes: Patient Needs MRI:YesNo If Yes, MRI Location: Patient Pays for MRI:YesNo Patient has filled out HIPPAYesNo Pick Up Hotel: