Microbiota Transplant Program - Peru

Microbiota Transplant Application

Complete the following sections to submit your pre-eligibility evaluation. All information is confidential and will be reviewed by our medical team.

Section 1 / 7

1

Patient Identification

Please provide your personal and contact information.

    2

    Primary Indication

    Select your primary diagnosis or indication for Microbiota Transplant.

    3

    Tell Us About Your Condition

    Please answer these questions specific to your selected diagnosis.

    4

    Medical History

    Please indicate your relevant medical history.

    Gastrointestinal History

    Immune Status

    Other Comorbidities

    5

    Additional Medical Information

    Please let us know if any of the following currently apply to you. This helps our team prepare the best care plan for you.

    6

    Current Medications

    List all current medications including antibiotics, biologics, probiotics, and others.

    7

    Pre-Procedure Evaluation

    Indicate which recent laboratory tests you have available.

    Lab results must be within the last 14 days.

    The medical and personal information in this application is treated as confidential. By submitting, you consent to ARDIG processing this information, including health data, to evaluate your request in accordance with our Privacy Policy.