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? Yes No Click 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 Name Phone # (if known) Medical Oncologist Name Phone # (if known) Surgical Oncologist Name Phone # (if known) Hospital Name Telephone #
