To process an order for a phototherapy device purchase or rental, we require two documents:
1. A Prescription -or- Physician's Written Order Form*
2. A signed Patient Order Form and terms attachment(s)
Download Patient Order Form
Please fax these items to Dermitech at 214-414-2533 or e-mail the forms to email@example.com. All forms must have a hand-written signature.
Patient Ordering Information
Dermitech - www.dermitech.com - 214-377-8144 - Copyright 2018
Providing Technology to Advance Skin Health and Rejuvenation
Payment and Financing Options
* - More information is needed from your doctor if insurance is to be used.
A blank Patient Order Form can be downloaded below: