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

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Application For Stem Cell Treatment Of Type 1 Diabetes - Adult

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

Please enable JavaScript in your browser to complete this form.

Your Name *

First

Last

Your Address *

Address Line 1

Address Line 2

City

State

Zip Code

Your Birthdate *

Your Phone *

Your Email *

Have You Been Diagnosed With Type 1 Diabetes? *

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

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

What Were Your 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 Do You Require Per Day?

How Many Units Of Short-Acting Insulin Do You 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

Your Weight (in pounds) *

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Your Height In Feet

And Inches

List All Of Your Prescription Medications (enter "None" if none)

List All Of Your Allergies (enter "None" if none) *

Do You Have Any Of These Other Autoimmune Disorders? Check All That Apply. *

Gluten-Sensitive Enteropathy / Celiac Disease
Crohn's Disease
Autoimmune Hepatitis
Hyperthyroidism / Hashimoto's Disease
Hypothyroidism / Grave's Disease
Adrenal Insufficiency / Addison's Disease
Rheumatoid Arthritis / Idiopathic Arthritis
Psoriasis / Psoriatic Arthritis
Dermatoid Arthritis
Dermatomyositis
Lupus
Scleroderma
Sjögren syndrome
Alopecia Areata
Parkinson's Disease
Alzheimer's Disease
Myasthenia gravis
Multiple Sclerosis
Autism
Pernicious anemia
Other (list below)
Possibly (list below)
None Of The Above

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

List All Vaccinations For Which You Have Records And Age When Vaccinated *

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

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IA2 Antibody Result

Date Of Result

Layout

Fasting Blood Sugar Result

Date Of Result

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Hemoglobin A1C Result

Date Of Result

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C-Peptide Result

Date Of Result

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GAD Antibody Result

Date Of Result

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ICA Antibody Result

Date Of Result

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IAA Antibody Result

Date Of Result

Enter The Name, Address, Phone Number, And Email Address Of The Doctor And/Or Clinic That Provides Your Diabetes 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 Next The 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.

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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