The VitalCough® System Supplement Replacement Prescription Form

This order form is for The VitalCough® System Supplement Replacement only. Please use the other prescription forms if you are ordering a different product.

Patient Information

*required field

Patient First Name*

Patient Last Name*

Patient Date of Birth (MM/DD/YYYY)*

Patient Street Address*

City*

State*

Zip Code*

Patient Contact Name (if other than patient)

Relationship to Patient

Patient Phone Number*

Patient Email

Is the patient currently in the hospital?* Yes
No

If yes, what is their discharge date? (MM/DD/YYYY)

Patient Medicaid ID #

Patient Medicaid ID # is required for Medicaid beneficiaries in MA, MI, NJ, and NY

Prescriber Information

Do not add space before or after Prescriber First Name, Last Name, or NPI Number.

Prescriber First Name*

Prescriber Last Name*

Prescriber Email*

NPI Number*

Prescriber License #

Prescriber License # is required for prescribers in Pennsylvania

Clinic Information

Clinic Name*

Clinic Street Address*

City*

State*

Zip Code*

Clinic Phone Number*

Clinic Fax Number*

Number of Refills

# of Refills*

Clinic Contact Information

Clinic Contact Person

Clinic Contact Phone Number

Clinic Contact Email

Following Physician/PCP

Physician/PCP Phone Number

Physician/PCP Email

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