Intake form

NOVYX Patient Consultation Form

Submitted to the NOVYX Medical Team to develop a personalized therapy plan
NOVYX Consultant Email (Internal Use Only)
Enter your NOVYX team email address. Example: yourconsultant@novyx.com
Patient Identification
Patient's Full Name

First NameLast Name
Preferred Language

Other
Date of Birth

MonthDayYear
Please enter as MM-DD-YYYY
Email Address
Enter the patient's email address. Therapy plan updates and follow-up communications will be sent here.
Patient's Phone Number
Enter the patient's best contact phone number. Format: (000) 000-0000.
Current Location
Enter the patient's current country and state/province. Example: "United States, Florida" or "Canada, Ontario"
Medical History
Gender

If female, pregnant or currently nursing?
Weight (in lbs)
example: 150lbs
Height (in feet and inches)
example: 5'5"
Primary Therapy Goals — Select all that apply
Cardiovascular Health
Heart Conditions or Cardiovascular Diagnoses
If you have been diagnosed with any heart condition, please enter the name and approximate year. Example: "Atrial fibrillation, 2018" or "Coronary artery disease, 2020." Enter "None" if not applicable.
History of Embolism, Stroke, TIA, or Heart Attack (MI)

Other
Are you currently taking any heart or blood pressure medications?

Other
How Many Alcoholic Drinks Per Week? (enter 0 if none)
Tobacco or Marijuana Use

Other
Chronic Conditions

For each field below, enter "None" if not applicable.
Do you have any chronic conditions?

Other
Chronic conditions details
Embolism / Stroke / TIA — date or age at diagnosis
Include blood clots, strokes, or TIAs (mini-strokes). Example: "Stroke in 2017, age 52" or "Deep vein thrombosis (DVT), 2020". Write "None" if not applicable.
Kidney Disease: Diagnosis & Date

Other
Liver Disease: Diagnosis & Date
Example: "Hepatitis C, 2010" or "Fatty liver disease (NAFLD), 2019" or "Cirrhosis, 2017". Write "None" if not applicable.
Neurological Diseases: Diagnosis & Date
Example: "Multiple sclerosis (MS), 2014" or "Parkinson's disease, 2019" or "Peripheral neuropathy, 2016". Write "None" if not applicable.
Spinal Problems: Description and Onset (When it started)
Describe any spine, neck, or back conditions. Example: "Herniated disc L4-L5, 2017" or "Cervical stenosis, 2020" or "Scoliosis since childhood". Write "None" if not applicable.
Muscle, Bone, or Joint Problems: Diagnosis & Date
Example: "Rheumatoid arthritis, 2015" or "Osteoporosis, 2019" or "Hip replacement, 2018". Write "None" if not applicable.
Autoimmune Diseases: Diagnosis & Date
Example: "Lupus (SLE), 2014" or "Type 1 diabetes, since birth" or "Crohn's disease, 2018". Write "None" if not applicable.
Cancer History: Type, Treatment, CURRENT Status:
Include the type of cancer, treatment received, and current status. Example: "Breast cancer, chemotherapy + surgery, 2016, in remission" or "Prostate cancer, radiation, 2019, stable". Write "None" if not applicable.
COVID-19 History

This information helps our medical team identify any relevant inflammatory history that may affect your therapy plan.
COVID-19 Vaccination Status
COVID-19 History — Infections & Dates
Have you had COVID-19? If yes, list approximate dates and how many times. Example: "Infected March 2021 and October 2022, both resolved." Write "None" if not applicable.
Long COVID / Post-COVID Symptoms
If you answered Yes to COVID-19 Infection History, describe any ongoing symptoms. Example: "Fatigue, brain fog, shortness of breath since March 2021." Write "None" if not applicable.
Known Allergies & Adverse Reactions
Known Vaccine Allergies or Adverse Reactions
Example: "Allergic to egg-based vaccines" or "Had hives after flu shot in 2019". Write "None" if not applicable.
Patient Goals & Clinical Summary
What Do You Hope to Achieve with NOVYX Therapy?
Please describe your personal health goals in your own words. Example: "I want to reduce my chronic knee pain" or "I want to improve my energy levels and overall quality of life." (Your final therapy protocol will be confirmed and tailored by our medical team.)
Primary Reason for Seeking Therapy
In your own words, briefly describe the main health concern that brought you to NOVYX. Example: "I have chronic lower back pain from a herniated disc" or "I have been diagnosed with multiple sclerosis and want to explore supportive therapies."
Have You Recently Experienced Unexplained Weight Loss, Fever, or Fatigue?

Yes, please specify
Have You Previously Received Stem Cell Therapy?

Yes — please describe below (where, when, and how many sessions)
Current Pain Level (0–10 Scale)

0

1

2

3

4

5

6

7

8

9

10

0 is No Pain, 10 is Worst Imaginable Pain
Describe Your Pain in Detail:
For each area of pain, please describe: (1) Where does it start? (2) Does it spread anywhere? (3) Rate it 1-10 (10 = worst). (4) What does it feel like? (shooting, aching, burning). (5) What makes it better or worse? Write "N/A" if you have no pain.
When did symptoms begin?
Enter an approximate date or timeframe. Example: "About 3 years ago" or "January 2022" or "Gradually over the past 5 years".
Current Symptoms — list all
List all symptoms you are currently experiencing. Example: "Back pain, fatigue, difficulty walking." Be as specific as possible.
Treatments Currently Using — medications, therapies, supplements
List ALL current medications (prescription and over-the-counter), supplements, and therapies. Example: "Metformin 500mg, Fish oil, Physical therapy twice a week, chiropractic care". Write "None" if not applicable.
Therapy Goals & Areas of Focus
Primary Diagnosis (if known)
Enter the patient's formal diagnosis if known. Example: "Multiple Sclerosis, Stage 2" or "Type 1 Diabetes." Enter N/A if not yet diagnosed.
Additional Goals
If your goal is not listed above, describe it here in your own words. Example: "I want to be able to walk without a cane" or "I want to reduce inflammation in my joints."
Relevant Surgeries or Additional Medical History
Please list any past surgeries, hospitalizations, or important medical events we should know about. Include the procedure name and approximate year. Example: "Knee replacement 2018, appendix removal 2010." Write "None" if not applicable.
Upload Imaging Reports (MRI, X-Ray, CT — Final Reports Only)

Please upload the written summary report from your MRI, X-Ray, or CT scan — this is typically a 1-2 page document provided by your doctor. Do not upload raw scan image files. Accepted formats: PDF or image files. You may skip this field if you do not have reports available.
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Treatment Protocol Notes (Consultant Use Only)
Enter the total number of injections, the amount per injection, and the site/location for each. Note: All injections use MSC, PRP, and Exosomes — except IV and intrathecal routes, which use MSC and Exosomes only.
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Helps the medical team understand the patient's daily environment and physical demands.
Occupation / Job Title
e.g. Software Engineer, Retired Teacher, Construction Worker, Nurse. Enter N/A if not applicable.
Physical Activity Level
Average Sleep Quality
Daily Stress Level

1

2

3

4

5

1 is Very Low, 5 is Very High
Diet & Nutritional Habits
e.g. Standard diet, Vegetarian, Keto, Mediterranean, Gluten-free, No restrictions. Enter N/A if unknown.
Work Environment
Helps the medical team understand the physical demands of the patient's daily work setting.
What Happens Next

Thank you! Here's what to expect next.
Thank you for completing your NOVYX consultation form. Our medical team will review your information within 48 hours and a personalized therapy plan will be prepared for physician review and approval.

If you have MRI, X-Ray, or CT scan reports to share, please also email them directly to: consultations@scistemcells.com

A member of our team will follow up with you shortly.

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CONSULTANT REMINDER (Internal): After submission, please ensure all relevant case notes are added to the patient's CRM profile under the "Notes" section. Allow up to 48 hours for the physician to return the treatment plan.
How did you hear about NOVYX?
Current Functional Limitations
Describe what the patient currently cannot do due to their condition. Example: "Cannot walk more than 50 feet, unable to work, severe fatigue limits daily activity." Enter N/A if not applicable.
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NOVYX Patient Consultation Form

Patient Identification

Medical History

Cardiovascular Health

Chronic Conditions

COVID-19 History

Known Allergies & Adverse Reactions

Patient Goals & Clinical Summary

Therapy Goals & Areas of Focus

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What Happens Next