Biliary Information Card Form Please fill out the requested information to the best of your knowledge and then submit the form. This will create a card which you should print and keep with you at all times, and show to any medical personnel who may be treating you. Patient Name*Email* Do you have a biliary stent or PTC tube?YesNoClick All That Apply Plastic (Temporary) Stent Metal (Permanent) Stent Unknown Stent PTC Tube Please indicate month/year the stent was placed (mm/yyyy)Please indicate month/year the tube was placed (mm/yyyy)Gastroenterologist NamePhone # (if known)Medical Oncologist NamePhone # (if known)Surgical Oncologist NamePhone # (if known)Hospital NameTelephone # This iframe contains the logic required to handle Ajax powered Gravity Forms.
