HMT Consultation

Please fill out the answers to the questions below in order to apply for an HMT consultation with a specialist. Not all applications will be accepted. We will try to accept as many applications for patient consultations as possible.

請回答以下的問題，以便向腸胃科專家申請免費諮詢。 並非所有的申請都會被接納，我們會竭盡所能地接受病人的申請。

Please provide your contact information 請提供您的聯繫方式

Question Title

* 1. Please provide your contact information 請提供您的聯繫方式

Please confirm your email address 請再次確認您的電郵地址

Question Title

* 2. Please confirm your email address 請再次確認您的電郵地址

How do you prefer to be contacted? 您希望我們透過什麼方式與您聯繫？

Question Title

* 3. How do you prefer to be contacted? 您希望我們透過什麼方式與您聯繫？

Do you have a gut or bowel disease diagnosis? 您曾接受腸道或腸道疾病的診斷嗎？

Question Title

* 4. Do you have a gut or bowel disease diagnosis? 您曾接受腸道或腸道疾病的診斷嗎？

If Yes, what diagnosis have you been given? 若有，您接受了什麼診斷？

Question Title

* 5. If Yes, what diagnosis have you been given? 若有，您接受了什麼診斷？

How did you first hear about Human Microbiota Transplant (HMT) 您是如何得知人類菌群移植 （HMT)?

Question Title

* 6. How did you first hear about Human Microbiota Transplant (HMT) 您是如何得知人類菌群移植 （HMT)?

How likely are you to accept HMT if prescribed by a doctor 若醫生處方HMT，您會否願意接受?

Question Title

* 7. How likely are you to accept HMT if prescribed by a doctor 若醫生處方HMT，您會否願意接受?

Very Unlikely 非常不可能 Undecided 未能決定 Very Likely 非常願意
Clear
i We adjusted the number you entered based on the slider’s scale.
When would you be available for a GI-Consultation 您願意在以下哪一天參加腸胃科醫生諮詢?

Question Title

* 8. When would you be available for a GI-Consultation 您願意在以下哪一天參加腸胃科醫生諮詢?

T