FlexRx Refill Request Form
Please complete the form below to request a FlexRx refill for your patient. Daavlin will provide the new code to the contact listed below. Refill requests are typically fulfilled within a few hours, but no later than one business day.
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Physician's Name
*
First Name
Last Name
Physician's NPI Number
*
Physician's Phone Number
*
We will call this number with the refill code if you select "physician" below or we have any questions about your request.
Physician's Email
Please list an email if you would prefer to be emailed.
Number of Exposures
*
100
250
I authorize Daavlin to remove FlexRx from my patient's device.
Did you know you can remove FlexRx from your patient's device? If you wish to remove FlexRx from your patient's device, please click the checkbox below. Daavlin will contact your patient to disable this feature.
Who should we contact with the new FlexRx refill code?
*
Physician
Patient
Patient's Phone Number
*
Number of Exposures
*
You may select exposures in multiples of 10 up to 250.
I am the physician listed above or a representative for the physician listed above and am authorized to submit this refill or removal request.
Clear
Submit
FRM-00109 [1]
Should be Empty: