Phothera — Refill Request

Healthcare Provider Information

Provider’s Name

NPI #

DEA #

Provider’s Email

Provider’s Phone

By providing your phone number, you consent to receive SMS messages from Phothera regarding refill codes, device support, and treatment updates. Message and data rates may apply. Reply STOP to unsubscribe or HELP for assistance.

Patient Information

Patient’s Name

Patient DOB

Patient’s Email

Patient’s Phone

You have your patient’s permission to provide their phone number for the purpose of communicating about their refill codes.

Refill Information

I understand that any falsification, omission, or unauthorized use of the refill code generator may subject me to civil or criminal liability. A copy of this order will be retained as part of Phothera’s records.