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Application For Stem Cell Treatment Of Alopecia Areata-Child

To initiate the application process for Throne's cord blood stem cell treatment targeting Alopecia Areata 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

Layout

Child's Date of Birth

Today's Date

Child's Age

Your Name *

First

Last

Your Address *

Address Line 1

Address Line 2

City

State

Zip Code

Your Phone *

Your Email *

Has The Child Been Diagnosed With Alopecia Areata? *

Yes, Within The Last Six Months
Yes, Within The Last Twelve Months
Yes, More Than Two Years Ago
No

If The Child Has Been Diagnosed With Alopecia Areata, What Was The Date Of That Diagnosis?

Is There A Family History Of Alopecia Areata?

One or more siblings
One or more parents
One or more grandparents
One or more first cousins
None of the above

If The Child's Alopecia Areata Has Been Diagnosed Using The Severity Of Alopecia Tool ("SALT"), Enter Your Most Recent Classification Under That Tool

S0 = no hair loss
S1 = 1–24% hair loss
S2 = 25–49% hair loss
S3 = 50–74% hair loss
S4a = 75–95% hair loss
S4b = 96–99% hair loss
S5 = 100% hair loss
No SALT Evaluation Has Been Done

Do You Want To See How To Calculate The Child's SALT Score? CLICK HERE

Child's Weight (in pounds) *

Layout

Child's Height In Feet

And Inches

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

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

List All Of The Child's Vaccinations For Which You Have Records 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 Colitis
Autoimmune Hepatitis
Type 1 Diabetes / Juvenile Onset Diabetes
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
Multiple Sclerosis
Childhood Autism
Other (list below)
Possibly (list below)
None Of The Above

List All Of The Child's Other Chronic Illnesses Or Disorders, Especially If Autoimmune, (enter "None" If none) *

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

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

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.

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.

Please Upload Photos / Images / Videos Of The Child's Hair Loss And Any Other Relevant Documents Here (Maximum of 5 files totaling no more than 25 megabytes)

Click or drag files to this area to upload. You can upload up to 5 files.

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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