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Telemedicine Consultation Form

Hashimoto's Disease

Please complete the following Clinical form if you wish to be treated for Hashimoto’s Disease.

Please review the Further Details Of Throne’s Stem Cell Treatment For Autoimmunity page at this link prior to submitting your request for Telephone Consultation since it will answer many of your general questions and allow us to focus on your specific questions during that consultation information.

Clinical History Form - Hashimoto's Disease

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

Your Sex

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?

Hashimoto's Disease Assessment Questions

Dry Skin (select one choice from below)
Fatigue (select one choice from below)
Increased Hours Of Sleep (select one choice from below)
Weight Gain (select one choice from below)
Cold Intolerance (select one choice from below)
Muscle Stiffness (select one choice from below)
Puffiness (select one choice from below)
Early Awakening (select one choice from below)
Feeling Blue (select one choice from below)
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.