microbiomeconsult.com

Client Intake Form

To ensure your testing kits are ordered and delivered correctly, please complete and submit the intake form below.

Once submitted, we’ll begin processing your kits for shipment.

Thank you for your response!

I am looking forward to working with you. You will receive your testing kit(s) within 1-2 weeks. Please watch your email inbox for a Welcome Note from Marilyn@microbiomeconsult.com.

Name

Date of birth (YYYY-MM-DD)

Phone number

Shipping Address

Do you suffer from chronic GI symptoms?(required)

Yes No

Do you suffer from GI symptoms that seem to be related to food?(required)

Yes No

Do you suffer from hormone related conditions (e.g., severe PMS, PCOS, and perimenopause)?(required)

Yes No I am Male

Is there any other information (e.g., symptoms, concerns, etc) you’d like to share that may be relevant to your Gut or Vaginal Microbiome Test?

Testing Kits are ordered through Tiny Health and Rupa Health. By checking this box you consent to the and Tiny Health and Rupa Health Teams ordering, processing, and handling your lab work