1. I authorize Helix Concierge to provide me the following procedure and treatment:
a. Autologous Stem Cells
b. Allogeneic Stem Cells
c. Platelet Rich Plasma
d. Hyaluronic Acid

3. Exosomes
2. I have been informed that the treatments being offered to me are not FDA approved for the given indications I am being treated for, but these
procedures have been used safely and successfully on other patients. The FDA has not approved any stem cell-based products, other than cord blood-derived hematopoietic progenitor cells for certain indications. Furthermore, the FDA has stated that there is a potential safety risk when you put cells in an area where they are not performing the same biological function as they were when in their original location in the body.
3. I have been advised on what the procedure entails and have had my questions answered to my satisfaction.
4. If I choose to use my own stem cells, I understand that my own stem cells will be extracted from my body fat and then re-injected into the specific
area to treat.
5. I have been informed that if I use Allogeneic stem cells, that they are derived from fetal tissue with consent.
6. I have been informed that if I use platelet rich plasma, that this is drawn from my own blood, processed, and then reinjected into the area of
treatment.

7. I have been informed that Exosomes are MSC-derived secretome produced through a patent pending technology that enables control of the protein type released by the stem cells. They are produced from vigorously tested, postnatal human umbilical cord lining stem cells (ULSCs), and is pre-COVID and cell-free.
7. I have been informed that not having the procedure and/or treatment is an option.
8. I have been informed of the risks, benefits, and complications associated with musculoskeletal injections.
9. I understand that results vary among different individuals and that there is no guarantee of results that may be obtained from these procedures
and/or treatments.

10. I understand that it is my responsibility to fully adhere to the post-procedure instructions which in turn will provide the best results for my
treatment.
11. I understand that insurance will not cover these types of services and that I am responsible for all applicable charges from the services rendered. I agree not to make a claim for PRP, exosomes and/or stem cell therapy with my personal insurance company.
12. I understand that payment must be made by cash, credit card, or use of a financing option we can provide you.
13. I understand that once the procedure and/or treatment has been administered, that I am not entitled to any refund for any reason including,
but not limited to, lack of response to treatment, treatment complications, and financial hardship. If you are unsatisfied with your treatment outcome, we will do our best to ensure you are completely satisfied.
14. I have had the opportunity to ask questions and receive answers to my satisfaction.
15. I understand the potential side effects, risks, and benefits of treatment.
16. I understand there are alternative treatment options.
By signing below, I consent to the treatment and/or procedure being offered to me by Helix Concierge and I am satisfied with the
explanation. I acknowledge that I have read or have had read to me the following consent and understand the information present.