AUTHORIZATION TO RELEASE INFORMATION TO RENOVIA INC. AND ITS DESIGNATED PHARMACY / DURABLE MEDICAL EQUIPMENT DISTRIBUTOR
If you prefer to print and fax your patient agreement to 888.503.7788., please click here.
Please note, iOS 11.x.x. users, please go to Settings–>Safari and disable the following if they are enabled: Prevent Cross-Site Tracking, Block All Cookies, and Ask Websites Not to Track Me. Once completed refresh this page in your browser.