Application – Type 1 Diabetes – Adult – Throne Biotechnologies

Your Name

First Name

Last Name

Your Address

City

State/Province

Zip/Postal

Country

Your Phone

Your email address

Your Birth Date

Your Weight (in pounds)

Your Height in Feet

And Inches

Have You Been Diagnosed With Type 1 Diabetes?

Yes, Within The Last Six Months

Yes, Within The Last Twelve Months

Yes, Within The Last Twelve To Twenty Four Months Ago

Yes, More Than Two Years Ago

Not Yet But I Am At Risk Based On Antibody Tests

Not Yet But I Am At Risk Based On Family History

If You Have Been Diagnosed With Type 1 Diabetes, What Was The Date Of That Diagnosis?

What Were Your Symptoms When First Diagnosed?

How Many Units Of Long-Acting Insulin Do You Require Per Day?

How Many Units Of Short-Acting Insulin Do You Require Per Day?

Is There A Family History Of Type 1 Diabetes?

One or more siblings

One or more parents

One or more grandparents

One or more first cousins

None of the above

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

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

If You Have Recent Blood Test Results, Please Enter Them Below

Hemoglobin A1C Result

Date of result

Fasting Blood Sugar (Glucose) Result

Date of result

C-Peptide Result

Date of result

GAD Antibody Result

Date of result

IA2 Antibody Result

Date of result

ICA Antibody Result

Date of result

IAA Antibody Result

Date of result

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

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

Required HIPPA Privacy Practices Notice: (Follow link below)

Yes, I have reviewed the HIPPA Privacy Practices Notice

HIPPA Privacy Practice Notice

Email Communication Authorization:

Yes, I give permission for Throne Biotechnology and Its doctors to communicate with me regarding my care by Telephone, Text Message, or Email.

If you are human, leave this field blank.

Treatment Application Form Type 1 Diabetes - Adult

If You Have Recent Blood Test Results, Please Enter Them Below

Treatment Application Form

Type 1 Diabetes - Adult