Follow the steps to complete the Prescription Order Form smoothly.

1. Press the ‘Get Form’ button to access the Prescription Order Form and open it in your preferred editor.
2. Enter the date at the top of the form, marking the original order or indicating if it is a reorder with changes or an exact reorder.
3. Provide the prescribing physician's name, along with their specialty, and include the address, city, and state.
4. Select the gender of the patient from the available options. Note that a fitter number is required for all Elvarex and Elvarex Soft orders.
5. Check the appropriate box(es) next to the diagnosis that applies, including options like edema, lymphedema, and others.
6. Fill in the order confirmation section with the fax number or email address where the order should be sent.
7. Complete the fields for the measurer's name and custom fitter number, including their phone number and facility name.
8. Provide the shipping information: ship-to address, city, state, zip code, country, and attention name.
9. Fill in the billing information: bill-to address, city, state, zip code, country, and attention name.
10. If paying by credit card, select the card type, then enter the card number and expiration date. Note that patient names should only be used for billing to the facility.
11. Include the purchase order number (P.O. #) along with the patient's date of birth and phone number.
12. Once all fields are completed, save the changes to the form. You may then download, print, or share the completed document as needed.

Start filling out the Prescription Order Form online to ensure timely processing of your order.