Apply For Stem Cell Treatment Of Type 1 Diabetes-Child – Throne Biotechnologies | Stem Cell Cure For Type 1 Diabetes

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Application For Stem Cell Treatment Of Type 1 Diabetes-Child

To initiate the application process for Throne’s cord blood stem cell treatment targeting type 1 diabetes for a child, kindly complete the following application.

Please enable JavaScript in your browser to complete this form.

Child's Name *

First

Last

Child's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Child's Birthdate *

Your Name *

First

Last

Your Address *

Address Line 1

Address Line 2

City

State

Zip Code

Your Phone *

Your Email *

Your Relationship To The Child *

Parent
Grandparent
Sibling (Brother/Sister)
Guardian
Other

Has The Child Been Diagnosed With Type 1 Diabetes? *

Yes, Within The Last Six Months
Yes, Within The Last Twelve Months
Yes, Within The Last Twelve And Twenty Four Months
Yes, More Than Two Years Ago
Not Yet But The Child Is At Risk Based On Antibody Tests
Not Yet But The Child Is At Risk Based On Family History
No

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

What Were The Child's Symptoms When First Diagnosed? *

Frequent Urination
Excessive Thirst
Excessive Appetite
Weight Loss
Extreme Fatigue
Blurry Vision
Other
None

How Many Units Of Long Acting Insulin Does The Child Require Per Day?

How Many Units Of Short-Acting Insulin Does The Child 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

Child's Weight (in pounds) *

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Child's Height In Feet

And Inches

List All The Child's Prescription Medications (enter "None" if none)

List All Of The Child's Allergies (enter "None" if none) *

List All Childhood Vaccinations And Age When Vaccinated *

Does The Child Have Any Of These Other Autoimmune Disorders? Check All That Apply. *

Gluten-Sensitive Enteropathy / Celiac Disease
Crohn's Disease
Ulcerative Collitis
Autoimmune Hepatitis
Hyperthyroidism / Hashimoto's Disease
Hypothyroidism / Grave's Disease
Adrenal Insufficiency / Addison's Disease
Juvenile Rheumatoid Arthritis / Juvenile Idiopathic Arthritis
Psoriasis / Psoriatic Arthritis
Juvenile Dermatoid Arthritis
Lupus
Scleroderma
Alopecia Areata
Multiple Sclerosis
Childhood Autism
Other (list below)
Possibly (list below)
None Of The Above

List All Other Chronic Illnesses Or Disorders, Especially If Autoimmune, (enter "None" If none) *

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

Layout

Fasting Blood Sugar Result

Date Of Result

Layout

Hemoglobin A1C Result

Date Of Result

Layout

C-Peptide Result

Date Of Result

Layout

GAD Antibody Result

Date Of Result

Layout

IA2 Antibody Result

Date Of Result

Layout

ICA Antibody Result

Date Of Result

Layout

IAA Antibody Result

Date Of Result

Enter The Name, Address, Phone Number, And Email Address Of The Doctor And/Or Clinic That Provides The Child's Diabetes Care

Email Communication Authorization: I give permission for Throne Biotechnology And Its Doctors ToCommunicate With Me Regarding The Child's Care By Telephone, Text Message, or Email. *

Yes

Required HIPPA Privacy Practices Notice (To See A Copy Of Our HIPPA Privacy Practices, See The Next Paragraph) *

Yes, I have been shown a copy of this office's HIPPA Privacy Practices Notice (to see our HIPAA Policy,, see below)

Click here to review our HIPPA Privacy Policy.

The Throne Stem Cell Treatment Is A Two Day Procedure. Please Enter Your Preferred Date To Begin The Procedure.

Thank you for your interest in the Throne Stem Cell Treatment. We will respond to your application within the next two business days.

Throne Biotechnologies, 10 Forest Avenue, Suite 110, Paramus, NJ 07652

Life is in

the Blood

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