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Telemedicine Consultation Form

Alopecia Areata (AA)

Please complete the following Clinical form if you wish to be treated for Alopecia Areata.

Clinical History Form - Alopecia Areata

If you wish to be considered for treatment of Alopecia Areata with Throne’s Stem Cell Educator Therapy, please submit the following information

Your Sex

Alopecia Assessment Questions

Estimated scalp hair loss
Do you also have loss of facial and body hair (alopecia areata universalis)
Are any of these factors present?
Has your alopecia been treated with any JAK inhibitor drugs, such as Baricitinib (Olumiant), Ritlecitinib (Litfulo, or Deuruxolitinib?
Do You Have Any Of These Other Autoimmune Disorders? Check All That Apply.
Are You Employed At This Time?
Do You Have Or Need A Caretaker And, If So, Who Supplies That Care?
DISCLAIMER: I acknowledge that Throne Biotechnologies Stem Cell Educator Therapy is experimental and is NOT approved by the U.S. Food and Drug Administration for the treatment of Alopecia Areata or any other medical condition nor does Throne Biotechnologies claim or warrant that Stem Cell Educator Therapy is safe or effective for the treatment of Alopecia Areata or any other medical condition.
Required HIPPA Privacy Practices Notice (to see HIPAA Policy (see our HIPPA policy at https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/npp_fullpage_hc_provider.pdf
Email Communication Authorization: I give permission for Throne Biotechnology And Its Doctors To Communicate With Me Regarding My Care By Telephone, Text Message, or Email.