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*

Format: (000) 000-0000.

Mobile Phone

By including your mobile phone number, you consent for Daavlin to communicate with you by text.Format: (000) 000-0000.

Address*

City*

State*

Zip*

Patient's Date of Birth*

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.Format: (000) 000-0000.

Physician Name*

Physician's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

How did you hear about Daavlin?*

Other: (Please Specify)

Condition or Diagnosis**

Other: (Please Specify)

7 Series - A slim, 6' tall, and powerful full-body device that is configurable with multiple lamp and door options.4 Series - At just over 4' tall, the 4 Series is ideal for children, dorm rooms, or localized treatments.1 Series - This compact unit is tailored for treating localized areas of the body such as the face, hands, feet, and moreDermaPal - Compact and powerful, the DermaPal is ideal for spot and scalp treatments.UV Series - A full-body cabinet that utilizes 360 degrees of lamps for fast, effective treatments.Other

If you selected "other", please type the name of the unit:

Shipping Method*

Yes, I am purchasing with medical insuranceNo, I am purchasing outright

Primary Insurance

Insurance Type

Upload Photos (Front & Back) of Your Insurance Card

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*

Insurance Company Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

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*

Insurance Company Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

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