Customer Inquiry Form – Thank You

Customer Inquiry Form – Thank You2017-05-26T22:26:45+00:00

Thank you for completing the Customer Inquiry Form, one of our team members will contact you within 24-48 business hours regarding your questions. To ensure a timely response we may respond by email, phone or text. Please be sure to have your licensed healthcare provider complete Step 2 – the Provider’s Authorization Form. Your healthcare provider must fax this form back to us at the number listed on the form.