Self Referral Start | The Functional Gut Clinic

I understand that in case my insurance fails to cover for the tests, I will be liable to pay. *

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I confirm that I am 16 years or older *

I consent to the Functional Gut Group and their partners processing my personal data, including my health data, obtained through this referral form in order to facilitate my GI physiology referral request *

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Self Referral Form - In Clinic

Please fill out this form and we will contact you to schedule your in-clinic testing