Synergy Medical Supply makes it convenient for our health-care facilities to fax an order:

1. Download the prescription form.
2. Please complete and print out prescription form with the required information:

• Date and Start Date and Length of Need 
• Patient Name and Address Demographics 
• Patient Date of Birth
• Patient Height & Weight 
• Fill Out the Appropriate Order Information
• Include any insurance or testing information with your order form
• Physician Printed Name and Signature are also Required

3. FAX the forms to Synergy Medical Supply toll-free at (888)461-3210