Prescription (RX) Intake

Send us your prescription

Share your prescription details below and upload a photo or copy of it. You can also email or fax it to our intake team.

Email your RX

maternalreliefco@gmail.com

Fax your RX

817-473-1839

Patient Information

First name*

Last name*

Date of birth*

Email*

Phone*

Prescription Details

Product category (if known)

Prescribed equipment / items*

What did your provider prescribe? Include quantities if known.

Do you currently have a prescription?*

Prescribing physician

Physician phone

Diagnosis or reason (optional)

Upload Prescription (Rx)

If you already have a prescription for the requested product(s), you may upload a clear photo or copy here to help us begin processing your request. Accepted: JPG, PNG, HEIC or PDF, up to 10 MB.

Anything else we should know?

I consent to Maternal Relief Co using this information to process my prescription and equipment order.