1. GENERAL DATA
Surname patient *
First name patient *
Sex patient male female *
Date of birth patient *
Nationality *
Address *
Postal code *
City *
Country *
Phone number *
E-mail address *
2. MIS FILE (medical information sheet)
Diagnosis
Main symptomatology, patient history with symptoms
Allergies
Blood group
Height
Weight (kg)
Medication
Previous medical findings
Assistive technology
Operative procedures so far
Nutritional needs
3. REQUIREMENTS FOR TREATMENT OF STEM CELLS3.1 MRT Magnetic resonance tomography of the brain and spine (Neurological disease)3.2 Recent blood lab values(red and white BC, coagulation, hepatitis, blood group, blood sugar, Hba1c)- not older than two weeks before arrival here.3.3 Neurological status for neurological disease3.4 blood group identitiy card3.5. all relevant medical data and medical documentation so far
I fulfill the requirements yes no *
Explanation *
4. EXCLUSION CRITERIA FOR TREATMENT SCT
Exclusion criteria exist yes no *
What exclusion criteria *
5. TRANSPORTABILITY
Transport sitting lying *
How many accompanying persons *
6. SPECIFY PAYMENT AGB Wiener Privatklinik
Payment Bank transfer Card payment Cash *
Special diets required or asked for *
Long-term medication *
Security
I accept evaluation of my data submitted *
7. YOUR DATA HAS BEEN SUCCESSFULLY SENT.Thank you.