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RDS Infusions
Business Office
4571 Old Valdosta Road
Nashville, GA 31639
229-551-9969

Tampa location (Dr. Shepard)
(Procedures are done at this location only)
4224 N. Tampania Avenue
Tampa, FL 33607
229-551-9969

NOTE: We strongly recommend that you maintain a relationship with your local gastroenterologist where you live as it will be impossible for us to provide those services long distance.

We value your privacy. Please read our privacy notice before submitting this form.

** We email every patient. If you do not receive an email from us please check your spam file. **

 

How old are you? *

 Under 18 years old 18 to 60 years old 61 years old or older

What is your gender? *

 Female Male

What is your current medical condition / diagnosis? *

What medications are you taking now? (check all that apply) *

 Antibiotics, for example: Metronidazole (Flagyl), Ciprofloxicin, Rifaximin (Xifaxin) Steroids, for example: Budensonide, prednisone, methylprednisolone (solumedrol) 5-Aminosalicylates, for example: Mesalamine (Pentasa, Lialda, Asacol), Sulfasalazine, Olsalazine Immune Modulators, for example: Azathioprine (Imuran), Mercaptopurine (6-MP), Methotrexate Tumor Necrosis Factor antagonist: Infliximab (Remicade) Tumor Necrosis Factor antagonist: Adalimumab (Humira) Tumor Necrosis Factor antagonist: Certolizumab (Cimzia) Natalizumab (Tysabri) I did not take any medicine (none) I don’t know what medicines I was taking

Please enter any medications not listed above.

What medications have you tried in the past? (check all that apply) *

 Antibiotics, for example: Metronidazole (Flagyl), Ciprofloxicin, Rifaximin (Xifaxin) Steroids, for example: Budensonide, prednisone, methylprednisolone (solumedrol) 5-Aminosalicylates, for example: Mesalamine (Pentasa, Lialda, Asacol), Sulfasalazine, Olsalazine Immune Modulators, for example: Azathioprine (Imuran), Mercaptopurine (6-MP), Methotrexate Tumor Necrosis Factor antagonist: Infliximab (Remicade) Tumor Necrosis Factor antagonist: Adalimumab (Humira) Tumor Necrosis Factor antagonist: Certolizumab (Cimzia) Natalizumab (Tysabri) I did not take any medicine (none) I don’t know what medicines I was taking Other medications or investigational therapies: please list them here

How many intestinal surgeries have you had? Do not count endoscopic procedures. *

 None 1 2 3 or more

Have you been receiving intravenous nutrition such as Total Parenteral Nutrition (TPN) or tube feedings over the last week? *

 Yes No

Are you having any other medical problems at this time? (check all that apply) *

 Heart problems Lung problems Kidney problems Liver problems Pancreas problems Brain abnormalities Infection or abscess High or low blood sugar Immune system problems High blood pressure Cancer None of these problems

Please enter any medical problems not listed above.

Who are the people currently directing your gastric care? (check all that apply) *

 I am taking care of my symptoms mostly by myself My family doctor, internal medicine, pediatrics, or gynecology doctor My gastroenterologist My nutritionist My naturopath My surgeon Doctors at an Inflammatory Bowel Disease or Crohn's Disease center

Please enter any caretakers not listed above.

In order for us to contact you, please provide your name, telephone number, email and postal mail adress in the boxes below. We will respond to your request as quickly as possible. If you have not been contacted within 3 business days, please call RDS Probiotic Infusions at (229) 551-9969. Thank you.

Full Name:*

Phone: *

Email:*

Street Address:*

Suite / Apt / PO Box:

City: *

State: *

ZIP: *

*PRIVACY NOTICE: Your privacy is important to us. We will not sell, share, or otherwise divulge your personal information.

I agree that I have read the privacy terms and accept them.*