Information
Card
Remove this page & carry it with the patient.
FORMULA
Type of Formula:
Medications:
Homecare Company Name:
Phone:
PLACE STICKER HERE
G-JET
®
Button
Information
Product Number:
Lot Number:
French Size:
Stoma Length (cm):
Jejunal Length (cm):
Balloon Fill Volume (ml):
PATIENT INFORMATION
Patient Name:
Healthcare Provider Name:
Phone:
Placement Date:
Fill in the above infomation or peel off die-cut sticker from tray.
28
Applied Medical Technology, Inc.
29
TYPE OF FEEDING
Bolus Y / N:
Continuous: Y / N:
Water to Prime Tube Before Feeding (ml):
Flow Rate (Formula/Hour):
Additional Water (ml):
Length of Feeding (Minutes):
Additional Water (ml):
SPECIAL INSTRUCTIONS
Save the MRI Safety Card
for your Records.
CONTACT INFOMRATION
Healthcare Provider (Physician):
Phone:
HCP:
Phone:
Call Today 1 800 869 7382
