Ophthalmic evaluation form

Thank you for your interest in ProgenCell. Please fill out and submit the Confidential Application below.  To evaluate your case we will need the following information. This will help us determine if ProgenCell could consider you eligible for this protocol and perhaps help improve your medical condition.

If you have any other medical condition and not an ophthalmic condition please fill out this form Evaluation Form .

Your case will be evaluated and answered in the next 48 hrs.

Your information is considered CONFIDENTIAL thus it is handled with total discretion. Your data will not be shared with any institution and it is not used to send spam email.


Full Name:
Phone Number:
Best time / day to contact:
Religion: (optional)
Gender: (Male / Female)
Marital Status:
Place of Birth:
Residence: (City, country)
Do you smoke?
Amount / Frequency:
Do you drink?
Drinks per week:
Do you use any drugs?
What / Frequency:
Practice any sport?
Type / Frequency:
Have any allergies?
Allergies to any medicine?
Any special diet?
Do you have or had some type of cancer in the last 5 years?

Current Illness

Reason for consultation:
First Symptom Date: Diagnostic Date:
Eye surgeries in the past: right eye? left eye?:
Initial symptoms:
Current symptoms:
Current medication & eye drops:
Last eye examination date & ophthalmologist name:
Visual acuity right eye (with and without correction):
Visual acuity left eye (with and without correction):
Intra Ocular pressure (right eye and left eye):
Diagnosis (right eye and left eye):
Treatments received on the past:
Other Illness present:
Other medication currently in use:
Non Ophthalmic previous surgeries (please explain cause and date):
Description of current condition and Comments (Autonomy, Special requirements, wheelchair, transport, passengers, physical help, limitations, etc):

For Female Patients

Number of pregnancies: Vaginal births: C-sections: Abortions:
Using hormone therapy:

Important: After being approved to participate in this research protocol, and before your arrival at ProgenCell®, we will require the following blood tests:

  • Complete Blood biometrics (with platelets)
  • Prothrombin time (PT)
  • Partial thromboplastin time (PTT)
* All Testimonials are from real patients. The results shown are typical but not guaranteed. The outcome of the treatment is uncertain and depends on each patient condition. The testimonials displayed (text, audio and/or video) are given verbatim except for correction of grammatical or typing errors. Some have been shortened. In other words, not the whole message received by the testimonial writer is displayed, when it seemed lengthy or not the whole testimonial seemed relevant for the general public.
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