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Telemedicine Consultation Form

Crohn's Disease

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

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 information.

Clinical History Form - Crohn's Disease

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

Your Sex

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?

Crohn's Disease History

Have You Been Diagnosed With Crohn's Disease?
What Were Your Symptoms When First Diagnosed? Check All That Apply.
What Are Your Symptoms Now? Check All That Apply.
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.