Fillable (17.5g/3.13g/1.6g) per 6 ounces HEALTHCARE PROVIDER INFORMATION

Fill Online, Printable, Fillable, Blank (17.5g/3.13g/1.6g) per 6 ounces HEALTHCARE PROVIDER INFORMATION Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

(17.5g/3.13g/1.6g) per 6 ounces HEALTHCARE PROVIDER INFORMATION

On average this form takes 3 minutes to complete

The (17.5g/3.13g/1.6g) per 6 ounces HEALTHCARE PROVIDER INFORMATION form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 13 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
FILL LINE
IMPORTANT
(17.5g/3.13g/1.6g) per 6 ounces
SUPREP Bowel Prep Kit is a split-dose (2-day) regimen. Both 6-ounce bottles are required for a complete prep.
FIRST DOSE: Begin Step 1 at _______PM the evening before your procedure and proceed as shown below:
You must complete Steps 1 through 4 using one (1) 6-ounce bottle before going to bed:
SECOND DOSE: Begin Step 1 at _____AM the morning of your procedure and proceed as shown above:
For this dose, repeat Steps 1 through 4 shown above using the other 6-ounce bottle.
NOTE: You must fi nish drinking the fi nal glass of water at least hour , or as directed, before your colonoscopy.
Pour ONE (1) 6-ounce
bottle of SUPREP liquid
into the mixing container.
STEP 1
Drink ALL the liquid in
the container.
STEP 3
Add cool drinking water to
the 16-ounce line on the
container and mix.
NOTE: Dilute the solution
concentrate as directed
prior to use.
STEP 2
You must drink two (2)
more 16-ounce containers
of water over the next
1 hour.
STEP 4
(Please see other page for additional instructions.)
HEALTHCARE PROVIDER INFORMATION
Name:
Address:
City:
State:
Zip:
Phone:
Fax:
2
s
Please read the full Prescribing Information and Medication Guide in the kit.
Provided as an educational service from
©2011 Braintree Laboratories, Inc. SU-12392
On the day before your procedure…
What You CAN do:
• You may have a light breakfast or have clear liquids ONLY;
please have nothing for dinner
What You CANNOT do:
• DO NOT drink milk
• DO NOT eat or drink anything colored red or purple
• DO NOT drink alcoholic beverages
Any of the following liquids are OK to drink:
• Water
• Strained fruit juices (without pulp) including apple, orange,
white grape, or white cranberry
• Limeade or lemonade
• Coffee or tea (DO NOT
use any dair
y or non-dairy creamer)
• Chicken broth
• Gelatin desserts without added fruit or topping
(NO RED OR PURPLE)
Note:
• SUPREP Bowel Prep Kit is indicated for cleansing of the colon as a
preparation for colonoscopy in adults
• Be sure to tell your doctor about all the medicines you take,
including prescription and non-prescription medicines, vitamins,
and herbal supplements. SUPREP Bowel Prep Kit may affect how
other medicines work
• Medication taken by mouth may not be absorbed properly when
taken within 1 hour before the start of each dose of SUPREP Bowel
Prep Kit
• The most common adverse reactions after administration of SUPREP
Bowel Prep Kit were overall discomfort, abdominal distention,
abdominal pain, nausea, vomiting, and headache
• If you have any questions about taking SUPREP Bowel Prep Kit,
call your doctor
To learn more about this product, please call 1-800-874-6756 or visit our W
eb site at www.suprepkit.com
(Please see other page for additional instructions.)
SPECIAL INSTRUCTIONS FROM YOUR
HEALTHCARE PROVIDER
YOUR PROCEDURE
Time/Date:
Location:
If you have any questions, please contact your
healthcare provider at:
May, 2013
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

(17.5g3.13g1.6g) per 6 ounces HEALTHCARE PROVIDER INFORMATION

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 9 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document