EXISTING HEALTHCARE PROVIDER REORDER

ORDER NOW - EXISTING HEALTHCARE PROVIDER REORDER

To receive case orders of ez2go products, complete the form below. Please note individual components are listed first, followed by kit combinations you normally purchase. If you have questions or need additional information regarding our products or the ordering process, please contact us at 1-800-403-9832. We appreciate your trust and look forward to serving you again.

ORDERED BY

PHONE NUMBER

PURCHASE ORDER

CLINIC, PRACTICE OR PHYSICIAN'S NAME

SHIPPING ADDRESS

CITY

STATE/PROVINCE

POSTAL/ZIP CODE

QUANTITY

Case of PEG Bottle

ITEM

ITEM DESCRIPTION

Case of PEG BOTTLE

PEG 3350 238gm bottle (36 Bottles per case)

PEG 17 gram POUCH

PEG 17gram POUCH

PEG 3350 17gm pouch

MAG CIT POUCH

Magnesium Citrate 16gm pouch

BIS-4 POUCH

Bisacodyl 5mg - 4 tablet pouch

SIMETHICONE POUCH

Simethicone 80mg chewable tablet pouch

CUSTOM KIT COMBINATIONS
We ship 20 kits per case unless otherwise noted

When ordering, indicate the number of cases you'd like to receive
Please check your order for accuracy

PB4

PEG bottle, 4 Bisacodyl tablets,

PB4-M

PEG bottle, 4 Bisacodyl tablets, Mag. citrate powder

PB4-S

PEG bottle, 4 Bisacodyl tablets, Simethicone (HI-30)

PB4-M-S

Peg bottle, 4 Bisacodyl tablets, Mag. Citrate powder, Simethicone

PB4-M2-S

PEG bottle, 4 Bisacodyl tablets, 2 Mag. Citrate powder pouches, Simethicone

PB4(-2-)M-S

PEG bottle, 2 - 4 Bisacodyl tablet pouches, Mag. Citrate powder, Simethicone

PB4-M-S2

PEG bottle, 4 Bisacodyl tablets, Mag. Citrate powder, 2 Simethicone pouches

PB4-S-P17-3

PB8-S-P17-2

PEG bottle, 8 Bisacodyl tablets, Simethicone, plus 2 17gm pouches of PEG 3350

PB8

PB8-M

PB8

PEG bottle, 2- 4 Bisacodyl tablet pouches

PB8-M

PEG bottle, 2- 4 Bisacodyl tablet pouches, Mag. Citrate powder

PB4-S2

PEG bottle, 4 Bisacodyl tablets, 2 Simethicone (HI-30)

COMPLETE

4 PEG 17gm pouches, 2 Mag. Citrate powder pouches, Simethicone (30 kits per case)

M2-B4-S2

2 Mag. Citrate pouches, 4 Bisacodyl tablets, 2 Simethicone pouches (HI-30)

If you would like to leave us a comment or do not see the custom combination that will work best for you, please leave us a note.

COMMENTS:

Your order will be processed within 24 hours, Monday through Friday. A confirmation email will be sent to you when the order has been shipped.

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INDIVIDUAL COMPONENT ORDERS ONLY