Get Prescription Order Form - Jobst

Filling out the Prescription Order Form - Jobst online is an essential step for users seeking to order specialized compression garments. This guide will provide you with clear, step-by-step instructions to ensure that all necessary information is accurately submitted.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to access the Prescription Order Form - Jobst and open it in your preferred online editor.
2. Indicate the date of the order in the designated field.
3. Select the order type by checking the appropriate box: Original Order, Reorder with Changes, or Exact Reorder.
4. Choose the appropriate product from the list, including options such as Seamed, Elvarex, Elvarex Soft, Seamless Soft, or Bellavar.
5. Specify the gender of the user by selecting either Male or Female.
6. Identify the diagnosis by checking all applicable boxes, such as Stasis Ulcer, Lymphedema, Varicose Veins, and others.
7. Provide the order confirmation details including the fax number or email address where the confirmation should be sent.
8. Fill in the BSN medical Inc. File number, as well as the patient’s name, ID Code, or File number. Include last name and first name in the designated fields.
9. Enter the patient's address, including city, state, and zip code. Include a phone number if required.
10. Complete the prescribing physician's details, including their name, specialty, address, city, state, zip code, and country.
11. Fill in the patient's date of birth using the month and year format.
12. Provide information for internal use, such as authorization number, prescriber number, and billing and shipping information.
13. If applicable, include credit card information for billing purposes with attention to allowed card types.
14. Review all entries for accuracy, then save your changes, download, or print the completed form for submission.

Start filling out your Prescription Order Form - Jobst online today!