Application – Alzheimer’s Disease – Throne Biotechnologies

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

Your Name

First Name

Last Name

Your Address

City

State/Province

Zip/Postal

Country

Your Address

Today's Date

Your Birth Date

Your age in years

Your sex

Female

Male

Your Phone

Your email address

Your Weight (in pounds)

Your Height in Feet

And Inches

List All Medications That You Take For ??? Disease, Enter "None" If None *

List any other autoimmune conditions that you believe that you have.

Enter The Name, Address, Phone Number, And Email Address Of The Doctor And/Or Clinic That Provides Your ??? Care

Are You Employed At This Time?

Yes, Full Time (Greater Than 30 Hours Per Week)

Yes, Part Time (Between 20 and 30 Hours Per Week)

Yes, Part Time Less Than 20 Hours Per Week)

Retired

Disabled, Unable To Work

Not Retired But Not Working At This Time

Do You Have Or Need A Caretaker And, If So, Who Supplies That Care?

I can function independently

I live with a family member or friend who provides caretaking services for me

Someone comes to my home to provide caretaking services for four or less hours per day

Someone comes to my home to provide caretaking services for eight or less hours per day

Someone comes to my home to provide caretaking services for twelve or less hours per day

One or more caretakers come to my home to provide caretaking services 24/7

I live in a care facility and that care facility provides my caretaking services

List All Other Chronic Illnesses Or Disorders (enter "None" If none)

List The Reasons For All Hospitalizations Of More Than One Day And The Years In Which They Occurred

List All Major Surgeries And The Years In Which They Occurred

List All Medications That You Take For Any Reason Other Than ???

List All Allergies To Any Drugs Or Anything Else. Enter "None" If None.

List All Vaccinations For Which You Have Records And Age When Vaccinated

Alzheimer's Disease Questions

Which clinical stage of Alzheimer's Disease best describes the patient?

Stage 1 - Persons appear cognitively normal, but pathological changes are happening in the brain and can be seen on imaging studies

Stage 2 - Prodromal stage: mild memory loss, but generally this is indistinguishable from normal forgetfulness.

Stage 3 - Progression into mild cognitive impairment (MCI). Individuals may get lost or have difficulty in finding correct wording.

Stage 4 - Moderate dementia; poor short-term memory. Individuals forget some of their personal history.

Stage 5 - Cognition continues to decline and at this point individuals need help in their daily lives. They suffer from confusion and forget many personal details.

Stage 6 - Severe dementia. Requiring constant supervision and care. Patients fail to recognizemany of their family and friends and have personality changes.

Stage 7- Individuals are nearing death. They show motor symptoms, have difficultycommunicating, are incontinent and require assistance in feeding.

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

Yes, I have been shown a copy of this office's HIPPA Privacy Practices Notice

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.

Yes

If you are human, leave this field blank.

Telemedicine Consultation Form Alzheimer's Disease

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

Alzheimer's Disease Questions

Telemedicine Consultation Form

Alzheimer's Disease