The Restroom Request Card makes it easier to discreetly communicate your IBD condition and request access to restricted restrooms when unexpected symptoms arise.

*Eligibility restricted to patients diagnosed with Crohn’s disease or ulcerative colitis.

Crohn’s Disease

Ulcerative Colitis

First Name

Last Name

Gender

Female

Male

Date of Birth

Email Address

Confirm Email Address

Address

Address 2 (Optional)

City

State

ZIP

When were you diagnosed?

Are you currently taking medication to treat your disease?

Yes

Not sure

Have you taken medication in the past to treat your disease?

Yes

Not sure

How often do you experience disease symptoms?

Every day

Weekly

Monthly

Rarely

How likely are you to talk to your gastroenterologist about a different treatment for your disease?

I'm planning on it

I'm considering it

I'm not ready yet

Do you have an appointment or a date set to talk with your doctor about different treatment options? If so, when?

Would you be willing to participate in a market research study? (Optional)

Yes

Which best describes you? (Optional)

Patient

Caregiver

For US residents only.
I understand that the information I've provided will be used only by AbbVie and its contracted third parties to mail, email, and phone me with helpful information on my condition and AbbVie treatments, products, and services, and for marketing and informational purposes. To be removed from our mailing list or request a copy of this information, contact: 1.888.857.0634.

Get More Information and
a Restroom Request Card

Register Now

Get More Information and a Restroom Request Card

Register Now

Get More Information and
a Restroom Request Card