Please complete this private patient intake form prior to your consultation

Next Step: Please complete this intake form.

This form collects essential health and lifestyle information to assist our medical team at Quantum Reset clinic in Medellin in evaluating your eligibility for Mesenchymal Stem Cell Therapy and preparing the necessary documentation.

Your provided information will be handled with strict confidentiality. Please complete all fields accurately to ensure personalized care and treatment.

Basic Information

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Biological Gender
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Marital Status
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Do you have children?
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General Intake

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Medical History

Select your primary diagnosis:
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Have you also been diagnosed with any of the following conditions?
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Do you currently have any of these symptoms?
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Have you recently had surgery in your ear(s)?
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Are you currently taking anticoagulants?
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Are you currently taking corticosteriods?
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Have you been diagnosed with cancer?
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Have you been tested for allergies?
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Do you have any allergies?
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Are you allergic to penicillin?
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Do you have any of the following vaccines?
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Have you had any of the following health screenings?
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Have you undergone surgery?
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Have you been anesthetized?
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Have you had any specialized tests performed?
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Emergency Contact

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Have you provided Quantum Reset with your clinical history?
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Lifestyle & Social Habits

Are you currently on a specific diet or weight control program?
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If yes, do you follow any of the following diets?
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Do you smoke?
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Do you drink alcohol?
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Do you use any recreational drugs?
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Do you consume any of the following products?
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Do you exercise?
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Advanced Directives Document

Do you have an Advanced Directives Document?
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Have you provided a copy to Quantum Reset?
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Religious Considerations

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Thank you for taking the time to complete the intake form.

We truly appreciate your cooperation as it helps us provide you with the best care possible.

Please press "Submit" to complete this form.

We look forward to seeing you soon!

Quantum Reset is dedicated to transforming health through innovative regenerative and integrative medicine.

Services

  • Pre-Treatment Protocols
  • Stem Cell Therapy
  • Exosome Therapy
    Hyperbaric Oxygen Therapy
  • Shockwave Therapy
  • Concierge Travel Planning

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