Phototherapy Product Order Form

Patient Name *

First

Last

DOB *

Phone *

Alternate Phone

Email *

Address *

City *

State *

Zip *

Shipping Address (if different from above)

Is there a different shipping address?

Yes
No

Shipping Name

Shipping Address

Shipping City

Shipping State

Shipping Zip

I prefer to be contacted by: *

Voice Call
Email
Text

Product Choice (click all that apply)

DermaLume 2X
Hand-held Wand,
2 Lamps
E0691 (upgrade)
Panosol II
6' Full-Body Panel,
4 Lamps
Panosol 3D
6' full-Body Cabinet,
8 or 10 Lamps
E0694

Panosol 3D Lamps Selection *

8 Lamps (Default)
10 Lamps (Upgrade Option)

Other Equipment

Other Equipment

Other Equipment Description

Lamp Type

Narrowband UVB Lamps (default)
Other

Confirmation

I confirm that the above information is accurate and complete to the best of my knowledge. I agree to follow my prescriber’s instructions for the proper use of this medical device.
It is important to understand the size, weight and electrical requirements of your device. Please discuss these details and any special delivery needs you may have with your Dermitech representative by calling 214-377-8144. Read our terms.

I confirm that I have read, and agree to the Terms And Conditions *

I have read and agree to the terms.

Who will be signing this order form? *

The Patient
Someone Else

Relation To Patient

Parent
Authorized Representative

If Authorized Representative Name:

If Authorized Representative, Reason patient can't sign:

Phone

The encryption, and transmission of this information complies with HIPAA protocols.