888-723-8819 (Toll-Free) info@synergymedsupply.com

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

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