By checking this box,
*
I authorize Theratechnologies to:
Send me text messages about my Mytesi® order to the phone number. I understand that standard data fees and text messaging fees may apply based on my mobile plan; and
Provide me with free educational information and marketing materials; and
Conduct surveys to measure my satisfaction with Theratechnologies products and services.
Patient First Name
*
Patient Last Name
*
Patient Email
*
Phone Number
*
Format: (000) 000-0000.
Address
*
City
*
State
*
Zip
*
Date of Birth
*
-
Month
-
Day
Year
Today's Date
*
-
Month
-
Day
Year
Electronic Signature
By checking this box, I attest that I am the person identified above, agree to the authorization provided in this form, and understand that this selection constitutes my electronic signature.
If you are the patient’s representative, identify your relationship to the patient and state the basis of authority
Authorized Representative Name
Authorized Representative Relationship
*
Authorized Rep Electronic Signature
By checking this box, I attest that I agree to the authorization provided in this form, and understand that this selection constitutes my electronic signature.
Submit
Record Type ID
Country
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