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Telemedicine Consultation Form

Amyotrophic Lateral Sclerosis (ALS)

Please complete the following Clinical form if you wish to be treated for Amyotrophic Lateral Sclerosis (ALS).

Throne Clinical History Form For Multiple Sclerosis

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

Your Name
Your Name
First Name
Last Name
Your Address
Your Address
City
State/Province
Zip/Postal
Country
Your sex
What type of multiple sclerosis have you been diagnosed with? Check one of the below:

Functional Systems Assessment. For Each Of The Functional Systems Listed Below, Estimate Your Impairment.

Pyramidal - muscle weakness or difficulty moving limbs
Cerebellar - ataxia , loss of balance, coordination or tremor
Brainstem - problems with speech , swallowing and nystagmus
Sensory - numbness or loss of sensations
Bowel and bladder function
Visual function - problems with sight
Cerebral functions - problems with thinking and memory
If you have not had an evaluation of your EDSS in the past year, do your own estimated assessment of the eight Functional Systems listed above by checking the box below that best matches your current condition.
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?
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.