Stem Cell Research Project Registration -3

Name*

First Last

Address

Street Address Address Line 2 City Province Postal Code

Best Phone Number*

Phone Type*

Cell
Home
Work

Email

By entering your email address you consent to us contacting you by email.

Enter Email Confirm Email

Are you a Canadian resident?

Yes
No

Are you between the age of 19-79?

Yes
No

Do you have osteoarthritis in a major joint? Please select a maximum of 2 joints:*

You will be randomized into one of 3 treatment groups containing active stem cells from either your lipoaspirate (fat), bone marrow or both. THERE IS NO PLACEBO GROUP.

Yes I understand
No I do not understand

The study involves 3 treatment visits 4 weeks apart to our Kelowna office (travel costs are the responsibility of the participant)

Yes, I understand
No, I am unable to make that commitment

In the absence of corporate sponsorship, the total cost to the participant for all 3 treatments is $7900.

Yes, I understand
Yes, I understand and would like to receive information about third party financing options
No, I am unable to make this financial commitment

Please select if you have any of the following:*

Surgery or Arthroscopy approximate date:

Cortisone or hyaluronic acid injection approximate date:

Do you have any allergies to any of the following medications:*

Lidocaine
Heparin
Epinephrine
None of the above

Do you have any allergies to any other medications? If yes, please list below.

Are you currently taking any of the following medications:*

Aspirin/ASA
Advil/Ibuprofen
Aleve/Naproxen
Warfarin/Coumadin or other blood thinner
Birth Control (pill, injection, IUD)
None of the above

Are you currently taking any other medications? If yes, please list below.

Are you currently taking any of the following supplements:

Curcumin/Tumeric
Omega 3 Fish Oils
Willowbark
Boswellia
None of the above

Family Physician Name

The city where your Family Physician's practice is located