Print & Sign

Donor-Recipient Agreement

FECAL MICROBIOTA TRANSPLANT DONOR-RECIPIENT AGREEMENT

Name of Donor:
Name of Recipient:


The Donor has agreed to supply the Recipient with fecal microbiota for medical purposes.

The Recipient confirms:

 

  • I have sought medical advice about use of fecal microbiota transplant (FMT) for my condition

  • I am aware that FMT is an experimental therapy

  • I have discussed the risks with my doctor

  • I will pay for all testing required, if Donor’s insurance does not cover it

  • I will not hold the Donor responsible for any unexpected outcomes I experience from FMT

  • I am aware that the arrangement can be terminated by either of us without notice

  • I will act in good faith in my dealings with the Donor.

  • I will keep donor’s name anonymous when discussing medical information except with my

    doctors & project team members.

  • I will promise complete privacy and anonymity of the donor’s name and not discuss the project

     

The Donor confirms:

  • I am in good health

  • I have not taken antibiotics in the last year

  • I have answered all the questions in the donor screening & and health survey sections honestly

  • I will share my medical records, when requested by Recipient or medical team for this project.

  • I will stop donating if I become unwell

  • I will practice safe or monogamous sex while donating

  • I will not inject, inhale or consume illicit drugs while donating

  • I will not take any prescription medications while donating, without notifying the Recipient

  • I am aware that the arrangement can be terminated by either of us without notice

  • I am aware the Recipient will be making reference to this project on her blog and website while

    keeping the donor’s identity and personal details completely anonymous.

  • I will act in good faith in my dealings with the Recipient and keep her name anonymous in

    conversations about the treatment but am welcome to spread the word about the procedure.

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Recipient                             Date

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Donor                                   Date

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