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Telemedicine Consultation Form

Type 1 Diabetes - Child Less Than Age 18

Please complete the following Clinical History form if you wish your child to be treated for Type 1 Diabetes.

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.

Clinical Form - Type 1 Diabetes - Children

Child's Sex

Have The Child Been Diagnosed With Type 1 Diabetes?
What Were The Child's Symptoms When First Diagnosed?
Is There A Family History Of Type 1 Diabetes?
Does The Child Have Any Of These Other Autoimmune Disorders? Check All That Apply.

If The Child Has Recent Blood Test Results, Please Enter Them Below

Required HIPPA Privacy Practices Notice: (Follow link below)

HIPPA Privacy Practice Notice

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