Consent Form for the Use of Stem Cells in Treatment

Consent Form

for the Use of Adipose Derived Stem Cells (ADSCs) in Treatment
Patient Name*
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctor Name
Treatment Facility
Date*

MonthDayYear
PURPOSE
This consent form is intended to inform you about the use of Adipose Derived Stem Cells (ADSCs) in your treatment and to secure your permission to proceed with the treatment.
Description of Treatment
Adipose Derived Stem Cells (ADSCs) are multipotent stem cells derived from adipose (fat) tissue. They have potential regenerative capabilities, and your physician has suggested their use in your treatment.
Potential Benefits
While individual results can vary, potential benefits of this treatment might include:
- Tissue regeneration and repair
- Reduction of inflammation
- Enhancement of healing processes
- Other therapeutic effects as specified by the physician
Acknowledgment and Consent*

I, the undersigned, have read this consent form (or it has been read to me) and I have had the opportunity to ask questions. All of my questions have been addressed to my satisfaction.I understand the nature of theADSCs treatment, its potential benefits, risks, side effects, and alternatives.I also recognize that there are no guarantees regarding the outcome of this treatment.I hereby provide my informed consent to proceed with the ADSCs treatment as described above.
Patient Signature*

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Date*

MonthDayYear
Doctor Signature*

Clear
Date*

MonthDayYear
Should be Empty:

Consent Form

PURPOSE

Description of Treatment

Potential Benefits