InvisibleMi Order Form
Referrer details
Clinic order code
Doctor name
Doctor email
Patient
Patient name
Date of birth
Tube ID
Order items
Order InvisibleMi+ Endometrium microbiome
Yes
No
Order InvisibleMi+ Vaginal microbiome
Yes
No
Sampling details
Date of sample collection
Sample collection attempt
1
st
2
nd
3
rd
4
th
Menstrual cycle
Natural
HRT
Cycle day at sampling
Medical history
Antimicrobial treatment in the past month?
Yes
No
If yes, specify (name, dosage, duration)
Probiotic treatment in the past month?
Yes
No
If yes, specify (name, dosage, duration)
Recurrent bacterial vaginosis (≥3 episodes in last 12 months)?
Yes
No
Additional comments
I confirm that the information provided is accurate to the best of my knowledge.
Submit order
