New Remedies

Fecal microbiota transplantation (FMT)

Informed Consent

protocol no RG2025LIV0091

Patient Name

Date of birth *

ID card

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Name legal representative

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date of birth *

ID CARD

We declare

Informed Consent DysbiosisAnd as proof of conformity, they sign this document in