Cerebral Palsy - It is a persistent brain disorder that presents before the age of 3 and is due to brain damage. It is not progressive and has no treatment except for the symptoms. It effects mainly movement and muscle flexibility, but can have cognitive disability and epilepsy.

Medical Forms for treatment with Cord Blood Stem Cell Protocols, Hepatitis C Treatment, Treatment For Macular Degeneration

Medical Forms

In order for us to determine if Stem Cell Transplantation Therapy will be effective for your particular condition; we will require you to fill out our Medical Evaluation Form.

This Form will be sent to our Medical Advisory Board so that they can provide a recommendation based on your current condition if you qualify for our Stem Cell Treatment Programs. They will also decide on what the proposed stem cell treatment protocol will be and the best Clinic/Hospital for you to travel to for your specific case.

Please download one of the following documents, fill out the Evaluation Form and return it to Stem Cells for Hope, Patient Services.

 If you would like the Medical Evaluation Form as an MS Word document, click on:

  MS Word Format


If you would like the Medical Evaluation Form as a .PDF document, click on:


    PDF Format


If you have any questions on how to fill out the Medical Evaluation Form please contact Patient Services at (631) 929 – 3900 for assistance.

Once you have completed the Medical Evaluation Form you can email it to:


You can FAX the completed Medical Form to “Patient Services” at (631) 929 - 3909.

Thank You.