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On Stem Cell Care India
Patient Information Form
Fields marked with the section headers below mirror what the clinical team reviews. Submitting this connects you with a case coordinator, free of charge.
Trouble with the form, or prefer a phone conversation first? Call International: +91 8743024344 · Domestic: +91 7838223336.
Fields marked (required) must be completed before the form can be submitted — your browser will highlight anything missing.
Before You Begin
Having these on hand makes the form quicker to fill out and gives the clinical team a clearer picture of your case.
- Diagnosis report — the most recent report confirming your condition, from your treating physician.
- Imaging or scan summaries — MRI, CT, X-ray, or other reports relevant to your condition, if available.
- Recent blood test results — routine blood work from the last few months, where possible.
- Current medication list — names and dosages of everything you're currently taking.
- Treatment history — a rough timeline of therapies already tried for this condition.
- Known allergies — any medicines or substances you're allergic to.
You don't need every document to start — the form works with whatever you currently have, and the case coordination team will follow up if anything further is needed.
What the Form Asks For
The form is organized into a few short groups so it's easy to complete in one sitting.
Personal Details
Contact information, date of birth, weight, height, and country of residence.
Medical Condition
The disease or condition, diagnosis date, present status, and symptoms.
Treatment History
Prior treatments, past stem cell therapy if any, and your expectations.
Medications & Habits
Current medications and dosages, smoking, and alcohol use.
Medical Background
Chronic conditions, recent illnesses, transfusions, and vaccinations.
Allergies & Reports
Known allergies and any recent blood test results you can share.
Prefer to talk it through instead? Reach a case coordinator directly via the Contact Us page or WhatsApp.
How the Review Process Works
What happens between submitting the form and getting a medical opinion.
- You submit the formYour medical history and current condition reach the case coordination team directly.
- Initial reviewA case coordinator checks the submission for completeness and may follow up for missing reports or details.
- Medical evaluationQualified members of the clinical team review your case against current treatment protocols.
- Written opinion, typically within 24-48 hoursYou receive a response on eligibility, possible approach, and next steps — with no obligation to proceed.
- Planning your visitIf you choose to move forward, the team helps with scheduling, accommodation, and — for international patients — travel and visa guidance.
International vs. Domestic Patients
The form itself is the same for everyone; what differs is the planning that follows.
Privacy & Confidentiality
How your information is handled once you submit it.
- Used for clinical review only — your submission goes to the medical and case coordination team, not for marketing purposes.
- Handled by qualified staff — reviewed by the same clinical team that authors and reviews treatment content.
- No obligation — a free medical opinion doesn't commit you to any treatment or further contact.
- Full details — see the Privacy Statement and Disclaimer for how data is handled and the investigational status of these therapies.
Frequently Asked Questions
Straight answers about filling out and submitting the patient information form.
What is the patient information form used for?+
It collects your medical history, current condition, and relevant test results so the clinical team can review your case before recommending next steps.
Is there a cost to submit the form?+
No. The form and the initial medical review are free, with no obligation to proceed with treatment.
How long does it take to hear back?+
Most submissions are reviewed by the clinical team within 24-48 hours.
What documents should I have ready before I start?+
Recent diagnosis reports, imaging or scan summaries, a current medication list, and any recent blood test results make the review faster and more accurate.
Do I need to fill this out if I already spoke to a case coordinator?+
Yes. The form gives the medical team a structured record of your condition even if you've already had an initial conversation with a coordinator.
Is my medical information kept confidential?+
Yes. Submissions are used only for clinical evaluation and are handled under the clinic's confidentiality practices.
Can international patients use the same form?+
Yes, the same form applies to domestic and international patients; international patients also work through the International Patient Guide for travel and visa steps.
What happens after I submit the form?+
The clinical team reviews your history, a case coordinator follows up with questions if needed, and you receive a written medical opinion on eligibility and possible next steps.
See also: Get a free medical evaluation Full FAQ Patient testimonials Contact us
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More ways to prepare for your evaluation and visit.
Get a Free Medical Evaluation
Start the diagnostic review that any care plan is based on.
International Patient Guide
Travel, visa, and planning steps for patients coming from abroad.
Patient Guide
The full overview of services, facilities, and support for patients.
Admission Process
What happens once your evaluation leads to a scheduled visit.
Plan Your Visit
Practical details for arranging your stay and appointments.
Patient Testimonials
Verified reviews and patient case studies.
Stem Cell FAQ
Broader answers on safety, eligibility, and pricing.
Meet the Clinical Team
The physicians and scientists who review every submission.
Continue Exploring
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Every case is different. A free medical evaluation gets you a direct, physician-reviewed answer for your specific condition — typically reviewed within 24-48 hours.
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