FlexRx Refill Request Form

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 NameLast Name
Patient's Date of Birth*

MonthDayYear
Provider's Name*

First NameLast Name
Provider's NPI Number*
Provider's Phone Number*
We will call this number with the refill code if you select "provider" below or we have any questions about your request.Format: (000) 000-0000.
Provider's Email
Please list an email if you would prefer to be emailed.
What type of device does your patient have?*
Important! Some of Daavlin's newer DermaPal models utilize a new type of FlexRx code. The following question(s) help us determine if your patient's DermaPal requires a legacy code or a newer model code.
PASSCxyz (where xyz are numbers)
If the device is displaying a 3-digit code preceded by the letter C (e.g. C123), what code is being displayed? This code is required to generate the next refill code.*
100250
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.
ProviderPatient
Patient's Phone Number*
Format: (000) 000-0000.
Number of Exposures*
You may select exposures in multiples of 10 up to 250.
By signing this form, you certify that you are the licensed provider listed above or an authorized representative for the licensed provider listed above. You also certify that you are authorized by the licensed provider above to submit this refill request.

Clear
FRM-00109 [5]
Should be Empty: