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 FullTreatment Summary:Intake Doctor Notes:Patient Needs MRI:YesNoIf Yes, MRI Location:Patient Pays for MRI:YesNoPatient has filled out HIPPAYesNoPick Up Hotel:Δ