Contact Us

To enquire about treatment, please complete the form below. A Regenecell Counselor will contact you. Should you wish to have your case evaluated by a physician, please complete the evaluation form.

Title: Mr. Mrs. Ms. Dr Prof. Gender: Male Female Patient First Name: Patient Surname: Date of Birth: (dd/mm/yyyy) Contact Person Name (if different) Country: City/Town: Email: Phone - Work: Phone - Home: Mobile: Fax: Skype Username: Which support groups are you affiliated to: Select the condition that needs treatment: ALS Autism Cerebral Palsy Diabetes Type II Heart Disease Multiple Sclerosis Parkinson's Disease Rheumatoid Arthritis Stroke Anti-ageing Other Preferred method of contact: Please Select Email Phone - Work Phone - Home Mobile Skype Preferred time to be contacted Select Time Morning Afternoon Evening Any Time Disease Explanation: I agree that the above information is correct and by submitting this information make it available to Regenecell to use with no limitation and/or restriction. I understand that stem cell therapy may not be an approved treatment procedure in my country, and is not a cure for any condition, degenerative disease or injury. Clinical benefits from this therapy cannot be guaranteed. Please ensure you are connected to the internet before submitting this form.