HUMAN WELLNESS CENTER - APPLICATION FORM

Thank you for your interest in Human Wellness Centers (HWC). Our mission is to help individuals overcome chronic pain, accelerate recovery, and optimize their health through our proprietary targeted regeneration protocol, featuring Mesenchymal Stem Cells (MSCs) combined with holistic healing modalities.

To determine if our protocol is the right fit for you, please answer the following questions. This application will help us understand your needs and whether a consultation is the next best step for you at this time.

What are you looking to achieve with stem cell therapy? *

Chronic pain relief (back, knee, shoulder, etc.)

Recovery from an undiagnosed or autoimmune condition

Post-injury or post-surgical recovery

Athletic performance enhancement & longevity

Overall health optimization & cellular regeneration

Anti-aging benefits

What specific pain points or health issues are you currently experiencing? (Briefly describe your condition and how it affects your daily life.) *

How long have you been dealing with this issue? *

Less than 6 months

6 months – 2 years

2+ years

What treatments have you previously tried? *

Prescription medication

Surgery or other medical interventions

Physical therapy

Holistic or alternative medicine (acupuncture, functional medicine, naturopathy, etc.)

Other stem cell treatments (please specify provider & results, if applicable)

None of the above

What has been your biggest frustration in trying to heal or improve your health? *

Why is now the right time for you to explore stem cell therapy? (Briefly explain what has led you to take action now.) *

On a scale of 1-10, how committed are you to investing in your health and taking the necessary steps for recovery? *

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Have you reviewed or researched stem cell therapy before? *

Yes, I have done my research and understand the process.

Somewhat, but I’d like more clarity before making a decision.

No, I am new to this and looking for expert guidance.

What is your level of financial preparedness for this treatment? (We offer premium, personalized care, and our protocol is an investment in your long-term health.) *

I am financially prepared and ready to move forward.

I may need financing or payment plan options

I am just researching for now and not ready to invest.

Are you open to a holistic, multi-faceted approach that includes post-treatment protocols (nutrition, supplementation, lifestyle adjustments)? *

Yes, I am committed to following the full healing protocol.

Maybe, I need more information.

No, I am only interested in the stem cell treatment itself.

Are you available for treatment at our center in Pereira, Colombia? (Our treatment protocol includes an in-person experience for optimal results.) *

Yes, I can travel for treatment.

Possibly, but I need more details.

No, I need to explore alternative options.

Our treatment packages start at $15,000. Would this be a feasible investment for you at this time? *

Yes

No

If we determine this is a fit, are you available for a 30-minute consultation in the next 7 days? *

Yes, I am ready to schedule a call.

I need more time, but I’m interested.

No, I am just gathering information.

How did you hear about us? *

Facebook

Instagram

Mike Medina

Brian Kong

Lucas Chavez

Jacobo Janna

Other (Specify Below)

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Full Name *

Phone *

Email *

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