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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
Fields marked with an * are required

Patient Information

Please Note: If required by your prescription, FlexRx: Exposure Limiting Software may be added to either of these control systems.

Accessories and Options

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 and letter of medical necessity must accompany all orders. Daavlin will contact me with information regarding my insurance benefits before my order will be finalized.

Insurance Options


I confirm that I have read Daavlin's HIPAA Privacy Policy (Download here)

I confirm that I have read Daavlin's Medicare Standards Policy (Download here)

I confirm that I have read and accept the Terms and Conditions of Sale Agreement (Download here)

I authorize Daavlin to acquire medical benefits for Durable Medical Equipment on my behalf