Order Request

* - Indicates a required field

Product Information

Manufacturer / Brand

Product Name *

Customer Information

First Name *

Last Name *

Your Relationship

Gender

Date of Birth

Phone *

Email *

Address *

Address Line 2

City *

State *

Zip *

Request Information

Have you consulted your doctor about this condition? * Yes No

How did you hear about us? *

How to reach you? *

Questions / Requests

R_x Prescription

Select an option below to provide us your prescription

Select a prescription option below * Upload my prescription now I will send my prescription to Minnesota Medical Technologies Corporation Request a prescription from my physician for me

Your request cannot be completed until your prescription has been provided to Minnesota Medical Technologies Corporation.

If you acknowledge and accept this, please continue.

Please Upload your prescription below.
If your prescription has an expiration date, please provide that as well.

Upload your prescription *
Exp. Date
Additional comments regarding your prescription

Please fill out the following fields, so we can get your prescription from them.

Facility Name *
Physician Name *
Physician Phone Number *
Physician Fax Number
Additional comments regarding your prescription

Product Information

Customer Information

Request Information

Rx Prescription

R_x Prescription