Kit Activation

I acknowledge that my Personal (Health) Data and remaining sample could contribute to further research, development, and enhancement of diagnostic techniques and potential therapeutic remedies. I consent to The BioArte's storage once pseudo anonymized, of:

• My Personal (Health) Data and analytical results.

• Both original and processed sample

and that it will be kept by The BioArte for a minimum period of 10 years.

The company will use this data, along with the remaining samples that have been pseudonymized, for scientific research (both internal and external) as well as commercial research in the field of human related microbiome. The aim of the is to gain a better understanding of the role microbiome in an individual's overall health and susceptibility to diseases, as well as their potential response to treatments. Consent can be revoked at any time as explained below.
Public and private healthcare institutions, bio-medical companies worldwide, can be granted access to the patient’s pseudonymized data for research purposes, with the relevant guarantees adopted to ensure legitimacy of the data transfer (especially if the recipient is in a non-EEA country).
Please visit www.thebioarte.com or contact [email protected] for updated information on the research projects in which your pseudonymised data may be used.

Please visit Data Privacy to consult our data privacy policy.

HAVING READ AND UNDERSTOOD THE INFORMATION ABOVE, I CONFIRM THAT:
i. I have read and understood the indication, purpose, characteristics, scope, procedure, success rate, complications, limitations, and economic cost of this test, and have had the opportunity to ask questions and any questions that I had were answered fully and to my satisfaction. I have also been given information on the implications of the test results, any possible follow up and where applicable, any further tests that might be required. I am aware that clinical and technical staff will be at my disposal for any questions or additional counselling that I may require once the results of the test are known.
ii. I understand that the results of this test are not a substitute to a medical diagnosis performed in a clinical setting provided by a healthcare professional. I accept that The BioArte does not take responsibility for the use, by me or my clinician, of the results obtained and any consequences of such use.
iii. I confirm that the information I have given, both personal and medical, is accurate and truthful. I acknowledge that the clinical team may reach out to me for additional clinical information, which may include details required for research purposes.
iv. In view of the complexity of the tests, results should be assessed alongside other clinical information by healthcare professionals. Consequently, I agree that the test report may be forwarded to the requesting clinician so that I can be offered the most appropriate advice.
v. I am not receiving any compensation as the participant nor will I be owed any funds, at this moment or in the future, due to any invention(s) resulting from research and development using my specimen(s).
vi. I understand that the results of this study may be used for medical or scientific purposes, may be presented, for example, at meetings, in scientific publications, and that they may be reported or published; however, I shall not be personally identified in any way, either individually or collectively.
vii. I have been informed that this informed consent can be withdrawn at any time.

I acceptI do not accept

Information on your medical history and any medication or issues you may be experiencing is crucial for the evaluation of your samples. The BioArte laboratory will analyze your samples, and our microbial expert will interpret the raw data together with the information you include in this form. This process allows the microbial expert to take into consideration your medical history and your current state when evaluating the results.

Kindly answer the following questions about your medical history, nutrition, and current state of health.

Personal data

Contact information

Sample information

Sample type:

FecalSkinOralNasalVaginalOther

Test type:

First timeFollow up

Reason for test

Please try your best to share all the information you can in order for our experts to be able to take into consideration all the possible scenarios and recommend a proper follow-up.

Medical history

1. Type of birth:

NaturalCaesarean

Do you suffer from:

2. Food intolerances?

YesNo

3a. Food allergies?

YesNo

3b. Other allergies?

YesNo

8. Select as many intestinal disorders that refer to you:

Abdominal swelling or painGastroesophageal refluxLactose intoleranceLactulose intoleranceGluten intolerance or sensitivityH. pylori infectionDiarrheaConstipationFlatulenceNoneOther

9. Select as many urogenital disorders that refer to you:

Hormonal disturbancesVaginosis and bacterial vaginitisCandida infectionsFertility disordersUrinary infectionsNoneOther

10. Select as many skin disorders that refer to you:

Environmental allergiesFood allergiesEczemaDermatitisAcnePsoriasisRosaceaNoneOther

11. Select as many cognitive / neurobehavioural disorders that refer to you:

Mental confusionMemory problemsLanguage difficultiesBalance disordersImpulsiveness, agitation, irritabilityParkinson'sAlzheimer'sAnxiety and stressNoneOther

14. (Optional) Additional medical information

Nutritional insights

15. Type of diet:

KetogenicPaleoRaw FoodMediterraneanVeganVegetarianOther

16. Do you practice Intermittent fasting?

YesNo

17. Have you recently lost a lot of weight?

YesNo

18. Do you have a family history of any relevancy to pathology?

YesNo

19. Do you suffer from diarrhea or constipation?

YesNo

20. Do you suffer from symptoms such as:

Gastric RefluxGastritisDysphagiaNone

21. What are your hydration levels?

22. Indicate the number of hours of sleep you get per night

23. Select the best option to describe your quality of sleep:

ExcellentOverall goodPoor

24. Do you take any food supplements (including probiotics)?

YesNo

25. (Optional) Additional nutritional information

Each of the 2 tubes has a sticker on them on which the sample collection date must be written. It is best to use a marker to write the date of when each sample was collected. If you have trouble writing the collection date on the tubes, you can take note of the dates and fill out the form below:

Please leave this field empty.

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