Meducate® Order Form GI Patient Education Brochures and Dietary Booklets Indicate the quantity of each title you would like to order, fill in the total amounts and complete the Ship To, Bill To and Method of Payment sections on the reverse side of this form. Email to [email protected] or fax to (717) 761-0216. 50 brochures per pack. 3 pack minimum. Price per pack: $23.50 GI Patient Education Brochures GI Patient Education Brochures Title English Qty Spanish Qty Title English Qty Spanish Qty Anal Fissure, Abscess, & Fistula MGI-38 ____ MSGI-38 ____ Helicobacter Pylori MGI-30 ____ MSGI-30 ____ Barrett’s Esophagus MGI-40 ____ MSGI-40 ____ Hemorrhoids MGI-10 ____ MSGI-10 ____ Celiac Disease MGI-50 ____ MSGI-50 ____ Hepatitis C MGI-42 ____ MSGI-42 ____ Cirrhosis MGI-14 ____ MSGI-14 ____ Hiatal Hernia MGI-08 ____ MSGI-08 ____ Colonoscopy MGI-19 ____ MSGI-19 ____ High Fiber Diet MGI-22 ____ MSGI-22 ____ Colon Polyps/Cancer MGI-01 ____ MSGI-01 ____ Irritable Bowel Syndrome MGI-03 ____ MSGI-03 ____ Constipation MGI-07 ____ MSGI-07 ____ Lactose Intolerance MGI-24 ____ MSGI-24 ____ Crohn’s Disease MGI-16 ____ MSGI-16 ____ Liver Biopsy MGI-27 ____ MSGI-27 ____ Diarrhea MGI-28 ____ MSGI-28 ____ Low Fiber Low Residue MGI-56 ____ MSGI-56 ____ Diverticulosis/Diverticulitis MGI-02 ____ MSGI-02 ____ Peptic Ulcer Disease MGI-09 ____ MSGI-09 ____ Endoscopic Ultrasound MGI-52 ____ MSGI-52 ____ Prev. of Colon Polyps/Cancer MGI-32 ____ MSGI-32 ____ Eosinophilic Esophagitis MGI-55 ____ MSGI-55 ____ Probiotics MGI-59 ____ MSGI-59 ____ ERCP MGI-20 ____ MSGI-20 ____ Rectal Bleeding MGI-29 ____ MSGI-29 ____ Esophageal Dilatation MGI-25 ____ MSGI-25 ____ Reflux Esophagitis & Stricture MGI-05 ____ MSGI-05 ____ Esophageal Manometry MGI-31 ____ MSGI-31 ____ Ulcerative Colitis MGI-15 ____ MSGI-15 ____ Esophageal Varices MGI-51 ____ MSGI-51 ____ Upper GI Endoscopy MGI-18 ____ MSGI-18 ____ Fatty Liver MGI-37 ____ MSGI-37 ____ Flexible Sigmoidoscopy MGI-23 ____ MSGI-23 ____ Total # packs _______ Gallstones MGI-17 ____ MSGI-17 ____ Gas MGI-06 ____ MSGI-06 ____ Total Cost of Merchandise (Total # packs x 23.50) $______ Gastritis MGI-46 ____ MSGI-46 ____ Shipping: $10 for first 3 packs; $2 for each additional $______ Gastroparesis MGI-45 ____ MSGI-45 ____ Subtotal $______ GERD MGI-39 ____ MSGI-39 ____ Personalization Charge (if applicable) $______ Heartburn and Reflux MGI-04 ____ MSGI-04 ____ TOTAL $______ GI Patient Education Brochure Kits GI Brochures GI Brochures Starter Kit Complete Kit The starter kit contains 1 pack (50 each) Title Item No. Price Qty The complete of our 10 most popular titles: kit contains • Colonoscopy • Heartburn and Reflux GI Brochures Starter Kit MGI-30 $235.00 ____ 1 pack (50 each) • Colon Polyps/Cancer • Hemorrhoids GI Brochures Complete Kit MGI-10 $900.00 ____ • Diverticulosis/Diverticulitis • Hiatus Hernia of all 40 titles. • Gastritis • High Fiber Diet GI Brochures 10 pocket display MGI-18 $99.00 ____ ««««« • GERD • Upper GI Endoscopy Personalized orders: Email letterhead or fax typewritten personalization. Personalized: YES NO Logos must be provided as camera ready art. One time fee of $55 for personalization or Change to existing personalization: YES NO change to existing personalization. Available for GI Patient Education Brochures only. Customer Account ______________________________ Dietary Booklets also available: See other side. (800) 451-5797 | (717) 761-0216 (Fax) | [email protected] | gi-supply.com 10 booklets per pack. 3 pack minimum. Dietary Booklets (10 booklets of the same title per pack) Dietary Booklets (10 booklets of the same title per pack) Title Item No. Price Qty Title Item No. Price Qty High Fiber D-01 $15.95 ____ Ash D-30 $6.95 ____ Low Fiber/Low Residue D-02 $6.95 ____ High/Low Potassium D-31 $15.95 ____ Gastroesophageal Reflux Disease (GERD) D-03 $6.95 ____ Low-Tyramine D-32 $10.95 ____ Peptic Ulcer Disease/Non Ulcer Dyspepsia D-04 $6.95 ____ Breast-Feeding D-33 $10.95 ____ Lactose-Free/Low-Lactose D-05 $10.95 ____ Pregnancy D-34 $10.95 ____ Gluten-Free D-06 $10.95 ____ Soft and Mechanical Soft D-35 $10.95 ____ Dysphagia-5 Levels Difficulty in Swallowing D-07 $19.95 ____ Increasing Calories D-37 $10.95 ____ Gastroparesis/Delayed Stomach Emptying D-08 $10.95 ____ High/Low Iron D-38 $6.95 ____ Anti-Dumping/Post-Gastrectomy D-09 $6.95 ____ Vitamin K Regulated D-39 $6.95 ____ Low Protein D-10 $15.95 ____ Oral Glucose Tolerance Test Preparation D-40 $6.95 ____ Low Fat (Diarrhea/GB) D-11 $10.95 ____ Nutrition and COPD D-41 $10.95 ____ Gas and Flatulence Prevention D-12 $10.95 ____ Nutrition and Cancer D-42 $10.95 ____ Colostomy, Ileostomy, Rectal Pouch D-13 $10.95 ____ High Blood Pressure D-43 $10.95 ____ Clear Liquid D-14 $6.95 ____ Nutrition and AIDS/HIV D-44 $10.95 ____ Full Liquid D-15 $6.95 ____ Weight Loss D-45 $19.95 ____ Fecal Fat Test-Preparation D-16 $6.95 ____ Finding Nutrition in Fast Food D-46 $10.95 ____ Low Copper/Wilson’s Disease D-17 $10.95 ____ Gestational Diabetes D-47 $10.95 ____ Vegetarian D-18 $6.95 ____ Nutrition for Older Adults D-48 $15.95 ____ Hypoglycemia D-19 $10.95 ____ Carbohydrate Counting for Type l Diabetes D-49 $10.95 ____ Osteoporosis D-20 $10.95 ____ Carbohydrate Counting for Type ll Diabete D-50 $10.95 ____ Reduced Sodium D-21 $10.95 ____ Ulcerative Colitis D-51 $10.95 ____ Gastric Bypass D-22 $10.95 ____ Crohn’s Disease D-52 $10.95 ____ Parkinson’s D-23 $10.95 ____ Cholesterol Connection D-3330 $23.95 ____ Low Cholesterol (Step 1 and Step 2) D-24 $15.95 ____ Mediterranean Pyramid D-26 $10.95 ____ Total # packs _______ Kidney Stone (Cystine Stones) D-27 $8.95 ____ Total Cost of Merchandise $______ Kidney Stone (Uric Acid Stones) D-28 $8.95 ____ Shipping: $10 for first 3 packs; $2 for each additional $______ Kidney Stone (Calcium Stones) D-29 $10.95 ____ TOTAL $______ Dietary Booklet Kits Dietary Booklets Dietary Booklets Complete Kit Starter Kit Title Item No. Price Qty The complete kit The starter kit contains 1 pack contains 1 pack (10 each) of our 6 most popular titles: Dietary Booklets Starter Kit D2000 $55.00 ____ (10 each) of all • High Fiber • Low Fiber/Low Residue Dietary Booklets Complete Kit D2200 $360.00 ____ 52 titles. • Clear Liquid • Gastroparesis ««««« • GERD • Low Fat (Diarrhea/GB) Ship to: Customer Account __________________ Bill to: Same as Ship to Facility _________________________________________________________ Facility _________________________________________________________ Address ________________________________________________________ Address ________________________________________________________ City ___________________________ State ____ ZIP ________________ City ___________________________ State ____ ZIP ________________ Phone ________________________ FAX ____________________________ Phone ________________________ FAX ____________________________ Contact Person __________________________________________________ Method of Payment: Email __________________________________________________________ Bill - Net 30 days. P. O. No. ________________________________________________________ Credit Card: VISA MarterCard Special Shipping Instructions: ______________________________________ Card No. ______________________________ Exp. Date ____________ _______________________________________________________________ Name on card ______________________________ Code ____________ Internal Use Only: Date ______________ Initials ____________ Sales Order ________________________________________ (800) 451-5797 | (717) 761-0216 (Fax) | [email protected] | gi-supply.com G-1208-07 | © 2020 GI Supply. All rights reserved. | Pricing effective Febuary 1, 2017 and is subject to change..