Call for a consultation 888-489-6665
What We Do
TBI Therapy Protocol
Packages and Payment
PRP and Insulin
Adult Stem Cell Treatment
Traumatic Brain Injury Treatment
Platelet Rich Plasma Injections
See if you qualify for treatment!!!
Patient Date of Birth
Relative to contact if unable to speak?
Who referred you?
If no one, how did you hear about us?
How long ago did the accident happen? What happened?
Were you in the hospital? Was surgery performed?
What were your initial symptoms?
What are your current symptoms? (select all that apply)
Nausea or vomiting
Sensitivity to light
Sensitivity to noise
Feeling slowed down
Feeling like “in a fog”
“Don’t feel right”
Fatigue or low energy
Trouble falling asleep
Nervous or anxious
Any other symptoms?
What medications/supplements are you taking?
Do you have any allergies? If so, to what drugs or substances?
Do you have any other medical history? Any previous surgeries?
What treatments have been performed? Any improvements since accident?
What questions do you have about the services offered at TBI Therapy?
Would you like to know more about: (select all that apply)
Stem cells and platelet rich plasma
Hyperbaric oxygen therapy
Nutritional supplements and dietary guidlines
IV and intranasal therapies
Brain imaging and mapping
Would you like to chat with another patient who has used the treatments at TBI Therapy?
Would you like to know what most other patients experience in outcomes from the treatments at TBI Therapy?
Any other questions, comments, or concerns?
I understand this form is not HIPAA compliant.
Yes, I understand.