Medical Prescription Form
HIPAA-Protected Prescription Upload Portal
Name
*
First Name
Last Name
Gender
Please Select
Male
Female
Phone Number
Birthdate
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
After your payment is processed or your insurance is approved, would you like your equipment delivered to the address listed above?If not, please share your preferred delivery location and any special instructions in the comments section so we can serve you better
Yes
No
Comment Section
Please upload a clear photo or scan of your prescription (Rx) and your insurance card.Your insurance card is required unless you will be paying out of pocket.For faster service, please be sure all required documentation is complete and easy to read.When your equipment is delivered, our team will need to collect the original physical copy of your prescription for our records.
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