🔒 Confidential & Secure
PHMX
Dr. Tina Hills, D.O., ABEM
Welcome.
We're glad you're here.
This short form helps our medical team take the very best care of you today. Plain language, large text, one step at a time.
~10minutes
100%confidential
2documents in one
(254) 616-9098 · phmx.life
About You
Let's start with the basics
We'll use this to pull up your file and keep your records accurate.
Your Address
Where do you call home?
Used only for your patient record.
How You're Feeling
How's your pain right now?
Just a quick check-in before your treatment. Tap the number that best describes how you feel right now.
😌1Minimal
😐2Mild
😟3Moderate
😣4Significant
😖5Severe
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.
Medical History
Do you have any of these conditions?
Check all that apply. This helps us make your treatment as safe as possible. If none apply, tap "None of these."
❤️ Heart conditions
🫁 Lung conditions
🛡️ Immune system / HIV
🩸 Blood or clotting
🔬 Liver or kidneys
🧠 Nervous system
⚠️ Autoimmune
🎗️ Cancer (current or past)
🤰 Pregnant or lactating
🦠 Active infection in joint/skin
None of these apply to me
Medications & Treatments
Are you currently taking any of these?
Some medications can interact with treatment. No judgment here — we just want to keep you safe.
Blood thinners (Warfarin, Eliquis, Xarelto, etc.)
Steroids (Prednisone, Dexamethasone, etc.)
Immunosuppressants
Chemotherapy drugs
Hormone therapy
Biologics or injectable medications
None of these apply to me
Recent Health History
A few safety questions
These help us make sure the timing of your treatment is right for your body.
In the past 90 days, have you had any of these?
🔪 Surgery
🏥 Hospitalization
🦠 Active infection
🌡️ Fever or unexplained illness
None of these in the past 90 days
Have you had adverse reactions to injections, IV therapy, or biologic products?
Yes, I have
No, I haven't
Have you ever been advised not to receive regenerative therapy by a medical professional?
Yes
No
Anything Else?
Is there anything else we should know?
Any medical condition, diagnosis, allergy, or history not listed above that a reasonable provider should know before your treatment?
Yes, there is
No, I'm good
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.
Today's Treatment
Which treatment are you receiving?
Your provider confirmed this at scheduling — just select the matching option below.
Stem Cell Therapy
Wharton's Jelly MSCs delivered by IV infusion or targeted injection for tissue repair and regeneration.
Exosome Therapy
Cellular signaling molecules that support tissue repair, reduce inflammation, and activate healing pathways.
Peptide Therapy
Physician-prescribed peptide protocol for healing, performance, recovery, mood, metabolic health, or longevity.
Combination Protocol
Two or more regenerative modalities delivered in an integrated treatment plan, personalized by Dr. Hills.
Before You Consent
What you should know first
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 (I & II), Hepatitis B & C, HTLV (I & II), 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 ≠ 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.
Consent — Section 1 of 4
FDA status — the full picture
We tell every patient this before they pay. Please read carefully.
NOT FDA-approved as a medical treatment. The HCT/Ps, exosomes, and compounded peptides used in this procedure have not been approved, cleared, licensed, or evaluated by the U.S. Food and Drug Administration for the diagnosis, treatment, cure, mitigation, or prevention of any disease or medical condition.
Experimental and investigational. This procedure is considered experimental and investigational. It is not recognized as standard medical care and outcomes are unpredictable.
The only FDA-approved stem cell uses are specific hematopoietic (blood-forming) applications — such as cord blood-derived stem cells for certain blood cancers and inherited disorders. No umbilical cord tissue product has been FDA-approved for regenerative medicine, joint health, anti-aging, or any of the uses discussed with you.
Peptides are compounded, not FDA-approved. Any peptide protocol provided by PHMX is prescribed on an individualized basis and sourced from a licensed compounding pharmacy. Compounded peptides are patient-specific preparations — not FDA-approved drugs. Safety, efficacy, and long-term outcomes for the uses commonly prescribed have not been established by the FDA.
PHMX makes NO medical claims. We do not claim this treatment will treat, cure, prevent, mitigate, or diagnose any disease or condition. All discussions, marketing, ads, and educational content are for informational purposes only — not medical advice, not a promise of outcome.
Processed by an FDA-registered tissue bank. The facility that processes our products is registered with the FDA and compliant with CLIA and CMS regulations. Strict donor-screening and lot-tracking standards apply to every product.
- The HCT/Ps, exosomes, and compounded peptides used in this procedure are NOT approved by the U.S. Food and Drug Administration for the diagnosis, treatment, cure, mitigation, or prevention of any disease or medical condition.
- The FDA has not approved any umbilical cord-derived tissue products for therapeutic use other than cord blood-derived hematopoietic progenitor cells for specific indications such as certain cancers and inherited blood disorders.
- Compounded peptides are patient-specific preparations produced by a licensed compounding pharmacy, not FDA-approved drugs.
- This procedure is considered experimental and investigational; it is not recognized as standard medical care.
- PHMX, its providers, and its affiliates make no representation, claim, or guarantee that this procedure will treat, cure, or prevent any medical condition.
- All information provided — on our website, in advertising, in consultations, and in educational materials — is for informational and educational purposes only. Nothing constitutes medical advice, diagnosis, or a promise of outcome.
By tapping 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.
Initialed
Consent — Section 2 of 4
Risks & uncertainty
Every medical procedure carries risk. We tell you this not to scare you, but because you deserve the full picture before you proceed.
Infection at IV or injection site
Bleeding, bruising, or hematoma
Swelling, edema, or inflammation
Nerve injury (temporary or permanent)
Pain or worsening of symptoms
Immune or allergic reaction
Disease transmission (known or unknown)
Vasovagal reaction (fainting, dizziness)
Nausea, vomiting, or headache
Numbness or tingling in the area
Tendon, muscle, or vascular injury
Equipment malfunction (vial, needle)
No improvement or dissatisfaction
Delay of other more-accepted treatments
Unknown or unforeseeable risks
Recurrence of original symptoms
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.
Risks include, but are not limited to: infection at the IV or injection site; bleeding, bruising, or hematoma formation; swelling, edema, or inflammation; nerve injury (temporary or permanent); pain or worsening of existing symptoms; immune or allergic reactions; transmission of communicable, infectious, or genetic disease (known or unknown); vasovagal reactions including fainting, dizziness, nausea, or vomiting; numbness, tingling, or unpleasant sensations in the treated area; injury to tendons, muscles, blood vessels, or adjacent structures; equipment malfunction including vial breakage or needle-related injury; fluid accumulation or recurrence of symptoms; no improvement or dissatisfaction with outcome; delay of other potentially effective or standard-of-care treatments; and risks that are unknown, unforeseeable, or not itemized here. No specific benefit is guaranteed. Any improvement experienced may be temporary or nonexistent. Individual outcomes vary and cannot be predicted.
By tapping 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.
Initialed
Consent — Section 3 of 4
You have options — and you're choosing freely
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:
Do nothing. You may choose not to pursue any treatment. Your condition may continue or worsen — but it is always a valid option.
Conservative care. Physical therapy, chiropractic, rehabilitation, laser or shockwave therapy. Often less costly and more widely studied.
Medication. Pain relievers, anti-inflammatories, or other prescription options through your primary care physician. These carry their own risks (including addiction, liver or kidney effects, GI bleeds).
Conventional injections. Steroid or corticosteroid joint injections — more widely used and recognized.
Surgery. For joint issues, procedures like arthroscopy or joint replacement are standard — each with its own risks, costs, and recovery time.
Your choice is voluntary. You have not been pressured to proceed. Your licensed provider will perform this treatment using their clinical judgment based on your individual circumstances. You may ask any question, request more time, or decline at any point — even after initialing this section.
Alternatives to the elective and investigational regenerative procedure include, but are not limited to: (1) doing nothing, with the risk that the condition may continue or worsen; (2) continuation of conservative therapy such as physical therapy, chiropractic, or rehabilitation, which may be less costly and is more widely studied; (3) oral pain medications or anti-inflammatory agents, which may carry risks of addiction, liver or kidney effects, gastrointestinal bleeding, or other adverse effects; (4) conventional injections including corticosteroid or other accepted joint injections; and (5) surgical options including arthroscopic or joint-replacement procedures, each carrying their own material risks. By electing this procedure, the patient may be delaying receipt of other more-accepted or less-costly treatments. The patient's consent is strictly voluntary; the patient is not obligated to proceed and may decline at any time prior to treatment.
By tapping 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.
Initialed
Consent — Section 4 of 4
Payment & financial terms
No hidden fees. No surprise bills. Here's exactly what you need to know.
Not covered by insurance. This is an elective, investigational procedure. No insurance plan — commercial, Medicare, or otherwise — covers this cost. We do not bill insurance and we do not submit claims on your behalf.
Payment due at time of service. All fees must be settled before your treatment begins. Payment responsibility rests entirely with you.
All payments are non-refundable. This applies regardless of outcome — including no improvement or dissatisfaction with results. If you seek additional medical care outside of PHMX for any reason, that cost is your sole financial responsibility.
By tapping 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.
Initialed
Patient Acknowledgments
Please confirm each statement
Tap each one to check it off. All ten are required before you sign.
The information I've provided on this form is complete, accurate, and truthful to the best of my knowledge.
I understand this is an elective, experimental, and investigational procedure involving Human Cellular and Tissue-Based Products (HCT/Ps), exosomes, or compounded peptides — not standard medical care.
I understand this treatment is NOT FDA-approved for the diagnosis, treatment, cure, mitigation, or prevention of any disease or medical condition.
I understand results are NOT guaranteed, individual outcomes vary significantly, and any improvement I may experience could be temporary or non-existent.
I understand PHMX makes no medical claims and that all information provided to me — on the website, in ads, in consultation, and in this form — is educational only and is not medical advice.
I understand that testimonials, reviews, or patient stories I may have seen reflect individual experiences only and do not predict or guarantee my results.
I understand alternative treatments exist (including doing nothing) and I am choosing this treatment voluntarily, of my own free will, without coercion.
I have had the opportunity to ask questions, and any questions I asked have been answered to my satisfaction.
I understand all payments are non-refundable, not covered by insurance, and that any follow-up care outside PHMX is my financial responsibility. I understand this form does not replace consultation with my primary care physician.
I understand failure to disclose relevant medical information may increase my risk and is my responsibility. I agree to report any adverse reactions or concerning symptoms to PHMX promptly. I also understand that viewing PHMX's website, ads, or marketing does not, by itself, establish a doctor-patient relationship.
0 of 10 confirmed
Final Step
Review & sign
Here's a summary of what you've completed. Type your full name below to electronically sign.
Patient—
Date of Birth—
Treatment—
Pain Score—
FDA Status✓ Initialed
Risks✓ Initialed
Alternatives & Voluntary✓ Initialed
Payment Terms✓ Initialed
Attestations✓ 10 / 10
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 voluntarily.
Type your name exactly as it appears above in the summary
Signature confirmed ✓
You're all set!
Your intake form and informed consent have been submitted. A copy is now on file with your care team. We look forward to taking great care of you.
Patient—
Treatment—
Submitted—
Initials4 / 4 ✓
Attestations10 / 10 ✓
(254) 616-9098 · phmx.life