Stem Cell Treatment For Ankylosing Spondylitis – Throne Biotechnologies

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

Your First Name

Your Last Name

Your Street Address

Your City

Your State Your State

Your Zip Code

Your Country

Your Phone

Your Email

Your Birth Date

Today's Date

Folder Name

File Name

Your Sex

Female

Male

Decline to State

Your age in years

Your Height in Feet

Your Height - Additional Inches

Your Weight (in pounds)

Your BMI

List All Medications Or Other Treatments hat You Take For Ankylosing Spondylitis, Enter "None" If None *

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

Check all of the medicines below that you currently use to treat your ankylosing spondylitis

Nonsteroidal anti-inflammatory drugs (Aspirin, Ibuprofen, Naproxen, Diclofenac, Celecoxib, Meloxicam, Mefenamic acid, Etoricoxib, Indomethacin, Ketoprofen, Ketorolac)

Tumor-necrosis-factor blockers (Remicade (infliximab), Enbrel (etanercept), Humira (adalimumab), Cimzia (certolizumab pegol), Simponi (golimumab), Simponi Aria (golimumab), Avsola (infliximab), Ixifi (infliximab) Renflexis (infliximab), Zymfentra (infliximab))

Interleukin-17A (IL-17A) inhibitors (Secukinumab, Ixekizumab, Brodalumab, Bimekizumab, Guselkumab, Risankizumab, Tildrakizumab, Ustekinumab)

Sulfasalazine

Steroids (prednisone)

Surgery (describe below)

Other (describe below)

None of the above

Do you have any of these complications of ankylosing spondylitis listed below? Check all those that apply.

List any other autoimmune conditions that you believe that you have, enter "None" if none

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, Enter "None" If None

List All Major Surgeries And The Years In Which They Occurred, Enter "None" If None

List All Medications That You Take For Any Reason Other Than Ankylosing Spondylitis, Enter "None" If None

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, Enter "None" If None

Are There Any Other Comments That You Wish To Make? Enter "None" If None

Days & Times For Telemedicine Consultation: Please list the best days of the week and times of day for us to reach you to discuss our stem cell educator treatment for Ankylosing Spondylitis.

How did you hear about Throne Biotechnologies Stem Cell Educator Treatment?

DISCLAIMER: Throne Biotechnologies Stem Cell Educator Therapy is experimental and is not approved by the U.S. Food and Drug Administration for the treatment of Ankylosing Spondylitis.

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.

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

Assessment Of Your Ankylosing Spondylitis Activity Score

DISCLAIMER: Throne Biotechnologies Stem Cell Educator Therapy is experimental and is not approved by the U.S. Food and Drug Administration for the treatment of Ankylosing Spondylitis.