New Account Information Request

To better assist you in the future, your answers to the list of questions below will provide us with the information necessary to set up your account:
1. Billing Address (including city, state, zip)
2. Shipping address(es) (if different from Billing Address)
3. Phone Number with area code
4. Fax Number with area code (if available)
5. Preferred method of payment (We accept personal check, money order or credit card. You may keep your credit card information on file with us if you prefer.
6. Please note that orders will not be shipped until payment is received.)
7. Preferred shipping method (Standard FedEx shipping is complimentary when using our Online Store)
8. Special shipping instructions (if necessary)
9. Would you like to join our Speaker's Club? (Includes quarterly newsletter, complimentary MedicAlert membership and exclusive discount promotions)
10. Some items require a prescription. Your clinician may fax your prescriptions to: 888.371-1530. If you have physical prescriptions in your possession, you may fax them to the same number or mail them to:

InHealth Technologies
"Prescriptions"
1110 Mark Avenue
Carpinteria, CA 93013

11. Our Indwelling style voice prosthesis are for insertion by a licensed clinician only. Therefore, these items are intended to be mailed to your clinician's address only. If your clinician needs the item to be shipped to your residence, they must complete an authorization form. Authorization forms are available on our website or may be requested via phone, fax or mail.

For your convenience, we are happy to email or fax our prescription form or Indwelling Ship-to Authorization form to your clinician's office on request.

Notice of Privacy Practices (HIPAA)

PLEASE NOTE: As of April 14, 2003, you will need to have a HIPAA consent form on file with InHealth. Only one form per customer is required. Please click here to download the consent form and after completing, mail or fax it to us per instructions noted on the form.
Thank You!