The undersigned patient/guardian does hereby acknowledge and confirm that they have received a consultation regarding local tissue Stem Cell Therapy and that this consultation shall not serve in any capacity as a replacement for consultation with their primary care physician/provider. The consultation is to discuss, without guarantee, the possibility that the infusion therapy could provide some therapeutic benefit to the patient. The patient/guardian is advised and understands that this procedure is not yet FDA-approved, and still considered experimental in nature. The recommendation(s) made by the consultant are not a substitute for the services and counseling made available to the patient and the patients primary care physician/clinic and/or specialist physician. It is further understood that the program designed for you, including any procedures or modalities, are not to be construed as treatments or remedies to diagnose, treat, cure, or prevent any disease or injury. It is the consultant’s obligation to provide you with the information you need in order to decide whether to consent to the special procedure(s) being recommended to you. Your signature on this document shall serve as verification that you have received that information and have given your consent to the procedure. You should therefore read this and any attached information carefully and ensure that all your concerns have been addressed by the consultant sufficiently before you give consent. The following procedure has been recommended: Upon your authorization and consent, this local tissue Stem Cell Therapy will be performed on you by an authorized provider.I understand that alternative treatments are available, and I understand the advantages and disadvantages of the proposed stem cell therapy. I am advised that although good results are the norm and expected, there is no guarantee, expressed or implied, as to the success of the treatment. There is always a possibility that I will have a result not meeting my expectations.