Biomebank Order Form

Order Details
Prescribing Specialist *

First NameLast Name
AHPRA Number *
Email*
Quantity: Colonoscopy Pack (4x50ml)
Quantity: Enema Pack (1x50ml)
Access to -80 freezer*

YesNo
FMT product will be used to treat:*

C. difficile infectionAnother clinical indication under the TGA Special Access Scheme (SAS)
It is the responsibility of the treating physician to apply for the SAS, here: https://compliance.health.gov.au/sas/

Send the TGA SAS-B approval letter or TGA SAS-A acknowledgement to BiomeBank at orders@biomebank.com. The SAS-B approval or SAS-A acknowledgement must be sent to BiomeBank prior to shipping of FMT.

If you have questions about this process, please contact BiomeBank at orders@biomebank.com or (08) 7223 0075.
Date order is required*

MonthDayYear
Proposed time of procedure*
*Please allow 4 hours for FMT to thaw

Order Details