I hereby certify that all information I have provided in my application and related communications is true, complete, and accurate to the best of my knowledge. I understand that any misrepresentation or omission may result in denial of evaluation or treatment.
I acknowledge and agree that:
- No established patient-provider relationship exists until I have undergone an in-person medical evaluation and history review by a qualified provider at Riordan Medical Institute. Any information, advice, or general recommendations provided prior to that evaluation (including via email, phone, forms, or website) is educational in nature only and does not constitute medical advice, diagnosis, or treatment.
- There are no guarantees, assurances, or warranties—express or implied—regarding the outcome, effectiveness, benefits, or success of any therapies offered. Individual results vary widely and may include no improvement or worsening of symptoms.
- To be considered for evaluation or treatment, I must have a qualifying chronic condition that results in either:
- Significant impairment of daily functioning, or
- Severe, persistent pain.
I confirm that I believe my condition meets this criterion based on my symptoms and medical history.
- The therapies available at Riordan Medical Institute, which may include regenerative medicine approaches, cell or biologic based interventions, or other advanced treatments, are investigational and/or off-label for many conditions. They have not been approved by the U.S. Food and Drug Administration (FDA) for my specific condition (or potentially for any condition), and their safety and efficacy for my use have not been definitively established through large-scale, FDA-approved clinical trials.
- I understand that these therapies are offered within the scope of medical practice but fall outside conventional standard-of-care treatments for many indications. I have been advised (or will be advised during evaluation) of potential risks, including but not limited to lack of benefit, adverse reactions, complications, unknown long-term effects, and the possibility that insurance may not cover any portion of evaluation or treatment.
- I have read and fully understand the above statements. I am signing this certification voluntarily and without duress, indicating my acknowledgment and acceptance of these terms as a prerequisite to proceeding with any further consideration as a potential patient.
