Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Stem Cell & Regenerative Medicine Consent Form
Your information
Patient Full Name *
Date of Birth
____ / ____ / ________
Treatment Type & Biologic Product
Target Anatomy / Treatment Area
Diagnosis & Clinical Indication
Risks & Complications Acknowledged
Contraindication Screening
Additional details
Current Medications
| Medication | Dose | How often |
|---|---|---|
Alternative Treatments Discussed
Please bring to your visit: baseline photo documentation
Informed Consent Agreement
Your practice's consent wording goes here.
Signature
Date
Patient Signature
Date
Date of Consent
____ / ____ / ________
Stem Cell & Regenerative Medicine Consent Form template from formisoft.com. formisoft.com/intake-templates/stem-cell-therapy-consent