Online Home Order Form

Patient's First Name *

Patient's Last Name *

Email *

Phone Number *

Address *

City *

State *

Zip *

Patient's Date of Birth *

Gender *

Female Male Prefer not to answer

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

Shipping Method *

Are you using Medical Insurance?* *

Yes, I am purchasing with medical insurance No, I am purchasing outright

Primary Insurance

Insurance Type

Upload a Photo of Your Insurance Card

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Check here if insurance information is the same as patient information.

Policy Holder Name *

Policy Holder's Address *

Relationship to Patient *

Employer / School Name *

Insurance ID Number *

Insurance Group / Plan Number *

Insurance Company *

Insurance Company Address *

Secondary Insurance

Click Here to enter Secondary Insurance (if applicable):

Name of Policy Holder* *

Policy Holder's Address *

Relationship to Patient *

Employer / School Name *

Insurance ID Number *

Insurance Group / Plan Number *

Insurance Company *

Insurance Company Address *

Terms

Order Confirmation

By entering my name I hereby confirm the above order is accurate and complete to the best of my knowledge. I understand that a doctor's prescription must accompany all orders. Daavlin will contact me regarding my insurance benefits and any payment information before my order will be finalized.

Name *

Today's Date *

Date