MyIBD.org - Medical Alert Restroom Access Pass



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Physician’s Order Form

The Foundation for Clinical Research in IBD has designed its Medical Alert Restroom Access Card for IBD patients to use when requesting access to a restroom. Physician’s practices may order larger quantities to distribute to their patients.

To order Medical Alert Restroom Access cards for your practice, please fill out the form below.

To minimize spam we have implemented a captcha system. Please type the two words that you see in the reCAPTCHA box at the bottom of the page then submit the form. If you have difficulty reading the words in the red box, click the reload button to create a new set of words.

Medical Alert Restroom Access Pass Physician’s Request Form
	* required fields
First Name*
Last Name*
Email*
Practice Name*
Address*

City*
State*
Postal Code*
Phone*
Quantity*

The card reads:
“The holder of this card has Crohn’s disease or ulcerative colitis. Colitis is painful and requires immediate access to a toilet facility. This patient cannot physically “hold it.” Please make your restroom available.”

This site has been underwritten thanks to sponsorship from Abbott Pharmaceuticals,
Procter & Gamble Pharmaceuticals, Centocor, Shire USA and UCB, Inc.