Adult Stem Cell Therapy & Platelet Rich Plasma
For HIPPA compliance and confidentiality, please use our patient portal-tab found next to the Form tab.
As a non-compliant HIPPA approach follow the instructions below.
There are two links below. Choose which insurance you have, Medicare or Private, to decide on the link to click upon. Once you do there is a series of sheets. You need to fill the first sheet out only! The rest of the sheets are various consent forms that you can keep for your records. When you arrive at the office we will have you sign those consent forms on an electronic device.
Fill the first sheet out completely! medications, problem list, past medical history, pharmacy information, family doctor information, allergies, past surgical procedures and so forth. We would request that you supply this sheet to us prior to your visit so that we can prepare for an efficient process.
You can fax it to- 941-953-5510
You can email it to- email@example.com
You can- with your phone camera- take a photo of the completed form that is legible and email it to firstname.lastname@example.org