Online Home Order Form

Patient Information

First Name*

Last Name*

Phone*

Email*

Address*

City*

State*

Zip*

Date of Birth*

Gender*

Female
Male

Physician Name*

Physician Phone Number

How did you hear about Daavlin?*

Other: (Please Specify)

Condition or Diagnosis*

Other: (Please Specify)

Product Information

Product Selection*

Prescription Information*

Other: (Please Specify)

Control System*

Accessories and Options

Special pricing shown is only available when accessories are ordered with a device.

Phototherapy Accessories: Iontophoresis Accessories:

Shipping Method*

Insurance Options

Are you using Medical Insurance?*

Yes, I am purchasing with medical insurance
No, I am purchasing outright

Primary Insurance

Check here if same as patient

Name of Policy Holder*

Policy Holder's Address*

Policy Holder's Phone Number*

Relationship to Patient*

Policy Holder's Date of Birth*

Employer / School Name*

Insurance ID Number*

Insurance Group / Plan Number*

Insurance Company*

Insurance Company Address*

Insurance Company Phone Number*

Secondary Insurance

Click Here to enter Secondary Insurance (if applicable):

Check here if same as patient

Name of Policy Holder*

Policy Holder's Address*

Policy Holder's Phone Number*

Relationship to Patient*

Policy Holder's Date of Birth*

Employer / School Name*

Insurance ID Number*

Insurance Group / Plan Number*

Insurance Company*

Insurance Company Address*

Insurance Company Phone Number*

Terms

HIPAA, Rights, and Responsibilities*

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

Terms and Conditions of Sale Agreement*

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

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*

Date*

Comments

This field is for validation purposes and should be left unchanged.

Online Home Order Form

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Patient Information

Product Information

Accessories and Options

Insurance Options

Primary Insurance

Secondary Insurance

Terms

Order Confirmation

General

Physicians

Patients

Online Home Order Form

Quick Contact

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Patient Information

Product Information

Accessories and Options

Insurance Options

Primary Insurance

Secondary Insurance

Terms

Order Confirmation

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