Free Consultation

Free Regenerative Medicine Consultation in Tijuana—Minutes from San Diego

Complete the form below to request your free consultation with VidaStem in Tijuana, Mexico. Our team will review your information and contact you to discuss treatment options, next steps, and how to plan your visit from San Diego or the U.S.

Identification File

Name *

Place of Birth *

Date of Birth *

Age *

Phone Number *

Email *

Reason for Consultation

Significant illness or disease:

When did your symptoms start?

What are your symptoms?

Current treatment:

Treatment Objectives

Select the options you wish to improve with this treatment:
Anti-agingSeeking to be in better physical conditionChronic fatigueHormonal imbalanceErectile dysfunctionNon-specific inflammationTendency for depression

Allergies

Do you have allergies? YesNo

Please mention allergen and type of reaction:

Medical History

Pre-Diabetes / Diabetes

YesNo

Age of diagnosis:

Treatment:

High Blood Pressure

YesNo

Age of diagnosis:

Treatment:

Heart Disease

YesNo

Age of diagnosis:

Treatment:

Respiratory Disease

YesNo

Age of diagnosis:

Treatment:

Cerebral Stroke

YesNo

Age of diagnosis:

Treatment:

Thyroid Disease

YesNo

Age of diagnosis:

Treatment:

Kidney Disease

YesNo

Age of diagnosis:

Treatment:

Liver Disease

YesNo

Age of diagnosis:

Treatment:

Neurological Disease

YesNo

Age of diagnosis/event:

Symptoms:

Treatment:

Fractures, Accidents, or Chronic Pain

YesNo

Age of incident:

Symptoms:

Treatment:

Spinal Issues

YesNo

Age of diagnosis:

Symptoms:

Treatment:

Muscle, Bone, or Joint Issues

YesNo

Age of diagnosis:

Treatment:

Autoimmune Diseases

YesNo

Age of diagnosis:

Treatment:

Surgeries

Please mention reason, type of surgery, year, and complications:

Medications

Please name any medication you may take, how you take them (include vitamins/supplements):

Oncological History

Do you have a history of oncological issues? YesNo

Are you within the 5-year treatment time frame? YesNo

Important: If you have a history of oncological issues and are within the 5-year treatment time frame, you are not a candidate for Stem Cell Therapy at this time.

I confirm that the information provided is accurate and complete.