English Spanish

Online Home Order Form

To take advantage of Daavlin’s Free Insurance Assistance Program, please enter the information below and submit the following by fax, email, or mail to Daavlin:

  • Fax: 419-636-7916
  • Mail: PO Box 626 Bryan, OH 43506
  • Email: phototherapy@daavlin.com
  • An enlarged copy of the front and back of your insurance card
  • Your “Doctor’s Written Order” Form – Signed by your doctor
  • 5 – 10 pages of relevant chart notes