Apply for stem cell assessment Name Which part (s) of your body is (are) to be treated? Where did you go for an X-ray or MRI or other scans? Please upload the report or email me: drhassanmubark@gmail.com Date-of-birth NHI (your hospital number) Gender MaleFemale Weight Phone number Email Address Any personal current or past history of cancer including skin cancer (give details please)? Any medical conditions and any surgeries? What are your current medicines (no doses required)? Allergies to medicine? Do you have Southern Cross insurance? if yes what is the policy number? Emergency contact name and phone number Who is your GP and what is his practice name? Send
