Online Home Order Form

Patient's First Name*
Patient's Last Name*
Email*
By including your email, you consent for Daavlin to communicate with you by email.
Phone Number*
Mobile Phone
By including your mobile phone number, you consent for Daavlin to communicate with you by text.
Address*
City*
State*
Zip*
Patient's Date of Birth*

MonthDayYear
Gender*

FemaleMalePrefer not to answer
Parent/Guardian Name (If Under 18)

First NameLast Name
Parent/Guardian Phone (If Under 18)
Please enter a valid phone number.
Physician Name*
Physician's Phone Number*
Please enter a valid phone number.
How did you hear about Daavlin?*
Other: (Please Specify)
Condition or Diagnosis**
Other: (Please Specify)
Accessories and Options

1 Series Stand $150.00Aquex Small Electrodes $60.004 Series UVB Filter $700.00Aquex Axillary Pads (Underarm) $60.00Fitover Glasses $19.957 Series Castors $80.00Aquex Back/Chest Pad $250.007 Series Wall Mount Kit $80.00Aquex Neck Pad $250.00Additional Goggles $7.50Aquex Replacement Towels $30.00
Shipping Method*
Are you using Medical Insurance?**

Yes, I am purchasing with medical insurance. Daavlin and/or Daavlin's In-Network Billing Agent will verify your insurance eligibility and benefits and contact you before processing your order.No, I am purchasing without insurance.
If purchasing without insurance, what is your method of payment:

CheckCredit CardPayment Plan/Financing
Primary Insurance

By completing this section, I authorize Daavlin or its billing agents to verify my insurance benefits for DME. I authorize direct billing to my insurance, assignment of benefits to Daavlin or its billing agents and release of medical records necessary to process my insurance claim. I understand there is no obligation to purchase to receive free verification of my insurance benefits, but once I instruct Daavlin or its billing agent to ship my order, payment in full is my responsibility.
Insurance Type
Upload photos of both the FRONT AND BACK of your insurance card. Forms submitted without this information are subject to processing delays.

Cancelof
Check here if insurance information is the same as patient information.
Policy Holder Name*
Policy Holder's Address*
Policy Holder Phone Number
Please enter a valid phone number.
Policy Holder Date of Birth

MonthDayYear
Relationship to Patient*
Employer / School Name*
Insurance ID Number*
Insurance Group / Plan Number*
Insurance Company*
Insurance Company Address*
Insurance Company Phone Number
This number can be found on your insurance card.
Secondary Insurance
Click Here to enter Secondary Insurance (if applicable):
Name of Policy Holder**
Policy Holder's Address*
Policy Holder Phone Number
Please enter a valid phone number.
Policy Holder Date of Birth

MonthDayYear
Relationship to Patient*
Employer / School Name*
Insurance ID Number*
Insurance Group / Plan Number*
Insurance Company*
Insurance Company Address*
Insurance Company Phone Number
This number can be found on your insurance card.
Terms & Conditions

By checking the following boxes, you confirm your understanding of and agreement to these Terms and Conditions.
Important! Here are the 4 items Daavlin needs to begin processing your order:
1. Patient Order Form (this form)
2. Physician's Written Order (completed by the prescriber)
3. If using insurance, 5-10 pgs of chart notes relevant to this diagnosis and order
4. If using insurance, a copy of the front and back of insurance cards to be billed
Order Confirmation

By entering my name I hereby confirm that the above information is accurate and complete to the best of my knowledge. I understand that a Physician's Written Order Form, chart notes, and insurance cards (if using insurance) must accompany my order. I have read, understand and agree to Daavlin's Terms and Conditions of Sale Agreement and I understand that all sales of medical equipment are final. I agree to follow my prescriber's instructions for proper use of this medical device.
Name*
Today's Date*

MonthDayYear
Date
FRM-00144 [0]
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