Age-Reversal Study Application Form

A1 Stem Cells is conducting a long-term clinical study which aims to document the effects of stem-cells on reversing the aging process at the epi-genetic level.

If you are interested in participating, please complete and sign the application below. Please allow 7-10 days to receive a response concerning your application.

Full name (required)

Email (required)

Date of Birth (required)

Home Phone:

Cell Phone:

Gender:
 male female

By signing this application form, you affirm that you are willing to:
• commit to participating in a study which lasts for:
 3 months 6 months 12 months

• commit to receiving an IV injection of 5 million stem cells per week for the duration of the study.
• complete periodic questionnaires during the study.
• receive periodic blood tests during the study.
• visit the clinic where the injections will take place in Tijuana, Mexico for a maximum of 1-3 hours per week.
• NOT make any changes to your diet or lifestyle during the period of the study.
• pay $400 for each weekly injection upon arrival. ‡
‡ Please note that all participants will be required to send a non-refundable deposit of $1600 (ie. pay 4 weeks of injections in advance) in order to secure their position in the study.

In order to best organize the schedule of all participants, please let us know:
• On which days would the weekly injections be most convenient for you?
(Check as many days as you wish)
 Monday Tuesday Wednesday Thursday Friday Saturday Sunday

• What hours would be most convenient for you?
(Please circle as many as you wish)
 9am – Noon Noon – 3pm 3pm – 6pm 6pm - 9pm

Date , 2014

Electronic Signature (required)