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At this time, minimum FMT donor laboratory screening consists of the following: HIV, syphilis, viral hepatitis, H pylori, common enteric pathogens, parasites and ova, C difficile, MDRO testing, & 16SrRNA/whole genome sequencing to assess normal flora periodically.

I will report any adverse events that I observe within 4 weeks after delivering FMT products prepared by Probiotic Infusions, whether or not I believe those adverse events to be causally linked to the use of FMT.

I have access to a laboratory-grade freezer (-20 C or colder, non-cycling) to store FMT products upon arrival, or a cooler with 5+ pounds of dry ice at all times, and/or I will arrange shipping to patients who have the same.

I will verify the presence or absence of true food allergies (including but not limited to itching, redness, swelling, dizziness or shortness of breath after consuming the allergy food, or optional IgE blood tests) in each patient, and I will specifically request FMT prepared with stool from donors excluding those foods in patients with true food allergies, noting exactly which foods they are allergic to.

Clinician name *

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