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Telemedicine Consultation Form

Multiple Sclerosis

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

Clinical History Form - Multiple Sclerosis

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

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What type of multiple sclerosis have you been diagnosed with? Check one of the below:

Functional Systems Assessment. For Each Of The Functional Systems Listed Below, Estimate Your Impairment.

Pyramidal - muscle weakness or difficulty moving limbs
Cerebellar - ataxia , loss of balance, coordination or tremor
Brainstem - problems with speech , swallowing and nystagmus
Sensory - numbness or loss of sensations
Bowel and bladder function
Visual function - problems with sight
Cerebral functions - problems with thinking and memory
Do your own estimate of your average EDSS over the past year by checking the box below that best matches your current condition.
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?

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 Multiple Sclerosis.

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.