If you prefer to place your order by fax rather than our website, our fax number is as follows: 1-866-416-3121.

Please review the below order form options and fill out the following required information on our order forms:

  • Date and start date and length of need
  • Patient name and address demographics
  • Patient date of birth
  • Patient height and weight
  • Fill out the appropriate order modality information
  • Include any insurance or testing information with your order form
  • Physician printed name and signature are also required

Example of a correct order form filled out can be found HERE.

After downloading the below Order Form for your patient's needs, please print, complete the required information above, and fax the form to our Customer Service Department at 1-866-416-3121.

ORDER FORM OPTIONS:

To order by fax, please fax to Customer Service at 1-866-416-3121.