• Please Fill Out Form Below

    CONFIDENTIAL + SECURE
  • PHMX Logo and Dr Hills

  • DR. TINA HILLS, D.O., ABEM

  • This short form helps our medical team take the very best care of you today. Plain language, large text, one step at a time.

  • Let's start with the basics

    ABOUT YOU | We'll use this to pull up your file and keep your records accurate.
  • Birth Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Where Do You Call Home?

    YOUR ADDRESS | Used only for your patient record

  • How's Your Pain Right Now?

    HOW YOU'RE FEELING | Just a quick check-in before your treatment.

  • A note about outcomes:

    Individual results vary significantly. Some patients report meaningful improvement; others notice minimal or no change. Your provider will review this score with you - no specific result is promised or guaranteed.

  • Do You Have Any Of These Conditions?

    MEDICAL HISTORY | This helps us make your treatment as safe as possible.
  • Check all that apply. If none apply, tap "None of these."*

  • Are you currently taking any of these?

    MEDICATIONS & TREATMENTS | Some medications can interact with treatment. No judgment here — we just want to keep you safe.
  • Check all that apply. If none apply, tap "None of these."*

  • A Few Safety Questions...

    RECENT HEALTH HISTORY | These help us make sure the timing of your treatment is right for your body.
  • Check all that apply. If none apply, tap "None of these."*
  • Have you had adverse reactions to injections, IV therapy, or biologic products?*
  • Have you ever been advised not to receive regenerative therapy by a medical professional?*

  • Is there anything else we should know?

    ANYTHING ELSE?
  • Any medical condition, diagnosis, allergy, or history not listed above that a reasonable provider should know before your treatment?*

  • This stays in your chart.

    Our team reviews this before your treatment. Failing to disclose relevant medical information can increase your risk - and that responsibility rests with you. The more we know, the better we can care for you.

  • Which Treatment Are You Receiving?

    YOUR TREATMENT
  • Your provider confirmed this at scheduling - just select the matching option below.*
  • PHMX Logo

  • What you should know first

    BEFORE YOU CONSENT | Before any legal paperwork, here is what this treatment actually is, how it's sourced, and what to expect from what you'll read below.

  • What HCT/Ps are

    "HCT/P" stands for Human Cellular and Tissue-Based Product. The products used in your treatment are biological materials derived from donated human umbilical cord tissue, recovered after normal, healthy live births. Nothing is harmed in the process - parents voluntarily donate tissue that would otherwise be discarded.

  • How we use them

    Your treatment is provided under the clinical judgment of a licensed medical professional. The FDA has not defined the specific use described here as "homologous use," so this use is considered experimental and investigational, outside of traditional FDA-approved indications.

  • Rigorously screened

    Every donor and product is screened for HIV (1 & II), Hepatitis B & C, HTLV (1 & Il), and Syphilis at an FDA-registered, CLIA-certified laboratory. However, no testing can eliminate 100% of disease-transmission risk - known or unknown pathogens.

  • We make no medical claims

    Nothing on our website, in our ads, in any consultation, or in this form is a claim that this treatment diagnoses, treats, cures, mitigates, or prevents any disease or medical condition. All information is educational only - not medical advice.

  • Testimonials equal results

    Any patient stories or examples you may have seen reflect individual experiences only. Your results may differ significantly. Outcomes cannot be predicted, and we make no promise you will experience any similar result.

  • FDA status - the full picture

    CONSENT - SECTION 1 OF 4 | We tell every patient this before they pay. Please read carefully.
  • Please acknowledge each point below.*

  • Full Legal Language

  • By signing below, you confirm you understand and accept the FDA status of this treatment, that it is not FDA-approved as a medical treatment, and that no medical claims are being made to you.*

  • Risks & Uncertainty

    CONSENT - SECTION 2 OF 4 | Every medical procedure carries risk. We tell you this not to scare you, but because you deserve the full picture before you proceed.
  • Please acknowledge each point below. Risks include, but are not limited to:*

  • Outcomes are not guaranteed - for anyone.

    Some patients report meaningful improvement. Others notice minimal or no change. Results vary significantly between individuals, cannot be predicted, and any improvement you experience may be temporary or non-existent. By proceeding with this elective procedure, you may be delaying other, more widely-accepted treatments that could be less costly or better studied for your condition.

  • Full Legal Language

  • By signing below, you confirm you have read and understood all of the risks listed above, including the possibility of unknown risks, no guaranteed outcomes, and that results vary significantly between individuals.*

  • You have options — and you're choosing freely

    CONSENT - SECTION 3 OF 4 | Before you move forward, we want you to know what the alternatives are — and to confirm that you are choosing this treatment voluntarily.

  • Other options you could choose instead of this treatment:

  • Please acknowledge each point below.*

  • Full Legal Language

    Alternatives to the elective and investigational regenerative procedure include, but are not limited to:
  • By signing below, you confirm you have considered the alternatives listed above and are choosing this treatment voluntarily, of your own free will, without coercion or pressure of any kind.*

  • Payment & financial terms

    CONSENT — SECTION 4 OF 4 | No hidden fees. No surprise bills.
  • Here's exactly what you need to know. Please acknowledge each.*
  • By signing below, you confirm you understand that all payments are non-refundable, this procedure is not covered by insurance, and any follow-up or outside care is your financial responsibility.*

  • Please confirm each statement

    PATIENT ACKNOWLEDGMENTS
  • Tap each one to check it off. All ten are required before you sign.*

  • Review & sign

    FINAL STEP | Type your full name and included your signature below to electronically sign. By typing your full name below, you are electronically signing this complete Patient Intake, Informed Consent, and Medical Disclosure document. This signature has the same legal effect as a handwritten signature under the federal ESIGN Act and state UETA statutes. You certify that you have read this entire document, understand its terms, and are executing it
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