Application – Celiac Disease – Child – Throne Biotechnologies

If you wish to be considered for treatment of Celiac Disease in a child with Throne’s Stem Cell Educator Therapy, please submit the following information:

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Street Address

Parent/Guardian City

Parent/Guardian State Parent/Guardian State

Parent/Guardian Zip Code

Parent/Guardian Country

Parent/Guardian Phone

Parent/Guardian Email Address

The Child is a Minor

Yes

Parent/Guardian Relationship to the Child

Child's First Name

Child's Last Name

Child's Street Address

Child's City

Child's State Child's State

Child's Zip Code

Child's Country

Child's Birth Date

Today's Date

Child's Sex

Female

Male

Decline to State

Child's Age In Years

Patient's Folder Name

Patient's File Name

Child's Height in Feet

Child's Height - Additional Inches

Child's Weight (in pounds)

BMI

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

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

Tissue transglutaminase antibodies (tTG, IgA) Result

Date of Tissue transglutaminase antibodies (tTG, IgA) Result

Total IgA Result

Date of Fasting Blood Sugar (Glucose) Result

Anti-Gliadin IgA Result

Date of Anti-Gliadin IgA Result

Endomysial antibody (EMA, IgA) Result

Date of endomysial antibody (EMA, IgA) Result

Hemoglobin Result

Date of Hemoglobin Antibody Result

Albumin Result

Date of Albumin Result

HLA DQ2 Result

Date of HLA DQ2 Result

HLA DQ8 Result

Date of HLA DQ8 Result

Enter The Name, Address, Phone Number, And Email Address Of The Doctor And/Or Clinic That Provides The Child's Celiac Disease Care. 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 The Child Takes For Any Reason Other Than Celiac Disease. Enter "None" if none.

List All Allergies To Any Drugs Or Anything Else. Enter "None" If none.

List All Of The Child's Vaccinations For Which You Have Records And Age When Vaccinated

Are There Any Other Comments That You Wish To Make?

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 Type 1 Diabetes in a child

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

DISCLAIMER: Throne Biotechnologies Stem Cell Educator Therapy is experimental and is not yet approved by the U.S. Food and Drug Administration for the treatment of Type 1 Diabetes.

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.

Telemedicine Consultation Form

Celiac Disease - Child Less Than Age 18

If you wish to be considered for treatment of Celiac Disease in a child with Throne’s Stem Cell Educator Therapy, please submit the following information:

Celiac Disease History

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

DISCLAIMER: Throne Biotechnologies Stem Cell Educator Therapy is experimental and is not yet approved by the U.S. Food and Drug Administration for the treatment of Type 1 Diabetes.

Telemedicine Consultation Form Celiac Disease - Child Less Than Age 18

If you wish to be considered for treatment of Celiac Disease in a child with Throne’s Stem Cell Educator Therapy, please submit the following information:

Celiac Disease History

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

DISCLAIMER: Throne Biotechnologies Stem Cell Educator Therapy is experimental and is not yet approved by the U.S. Food and Drug Administration for the treatment of Type 1 Diabetes.

Telemedicine Consultation Form

Celiac Disease - Child Less Than Age 18