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Patient Admission Form & Information
Home
Test
Test
Stool Donor Application
Do you live in Sydney?
*
Yes
No
How old are you?
*
Under 13 years
13-55 years
Over 55 years
Have you had antibiotics in the last 3 months
*
Yes
No
Do you currently work in:
*
Aged Care
Child Care Centre
Teaching Kindergarten to year 2
Acute Care Wards in Hospitals
None of the above
Have you been diagnosed with a Gastrointestinal condition?
*
Yes
No
Do you suffer from any Blood borne disease or STI?
*
Yes
No
Have you ever noticed blood in your stool?
*
Yes
No
Have you ever had cancer?
*
Yes
No
If you are accepted as a Donor do you agree to NOT consume shellfish or processed meats-salami,ham and sausages. You must also ensure you follow a healthy, high fibre diet and drink at least 1 litre of water per day
*
Yes
No
Do you agree to NOT take antibiotics whilst donating? (If you take antibiotics you will not be permitted to continue as a donor for a certain period of months)?
*
Yes
No
Do you agree to undergo a telephone interview and a face to face interview and stool and blood testing as part of the process to become a donor?
*
Yes
No
Do you agree to drop off your stool to the Centre for Digestive Diseases in Five Dock daily Monday- Friday, no later than 3 hours after opening your bowels?
*
Yes
No
If you become a donor do you agree to a weekly stool test, and three monthly blood test? The stool test will be from your donation. However, you will need to attend your local pathology centre for the blood test.
*
Yes
No
Do you have a Medicare card?
*
Yes
No
Do you agree to pay for all out of pocket expenses related to testing of blood and stool
*
Yes
No
Great! It looks like you might be right for the Donor program. Please add your contact details below so one of our Donor team can contact you.
Name
*
First
Last
Phone number
*
Your Date of Birth
*
Email
*
Address
*
Street Address
Address Line 2
Suburb/city
Postcode
Privacy
This page is only sent to the Donor team nurse. It is not stored, kept or shared ever.