Exosomes Screening Questionnaire
Name:*
Facility Name:
Address:*
Telephone Number:*
Email Address:*
Website:
Medical License (if applicable):
NPI Number:
State:*
Practice Overview
Type of Practice:
Stem Cells Offered:
Other Regenerative Therapies:
Patient Goals/Conditions:
Interest in Exosomes
What sparked your interest in exosome therapy?
How do you plan to use exosomes?
Injectable exosomes Topical exosomes Not sure yet
Treatment areas of interest:
Clinical Capabilities
Experience with biologics/injectables?
Facility licensed for injectables?
Do you have a medical director?
Implementation Goals
Ideal integration timeline:
Planned use of exosomes:
How do you introduce new treatments to patients?
Patient Volume & Business Model
Weekly patient volume:
Pricing for regenerative/premium services:
Support Needs:
Training support Patient education materials Marketing tools Protocol development Compliance documentation
Compliance & Education
Familiarity with regulatory guidance?
Need compliance overview?
Do you have cold storage (-86°C)?
Storage notes:
Fit & Follow-Up
Top goals for exosome therapy:
What does success look like (60–90 days)?
Interested in a 30-minute Zoom call?
Additional Notes:
Preferred Follow-Up Date: