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This is the preliminary initial evaluation/disclaimer form which needs to be filled out. There is no cost for having this reviewed. Please type in your name in the signature area.

Filling out the form does not in any way obligate the person to receive any procedure, nor does it imply that they will be accepted for the same.

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I, the undersigned, understand that no guarantee or claim, expressed or implied is made with regards to the efficacy of an infusion of autologous stromal vascular fraction (SVF) or of autologous stem cells derived from bone marrow. I fully understand that the use of SVF, commonly known as autologous adipose (fat) stem cells or of autologous stem cells derived from bone marrow, are experimental procedures which should only be used as a last resort after traditional medical approaches have been investigated and tried in accordance with standard medical advice.









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