Delivery Confirmation

TO CONFIRM DELIVERY:

Please be aware that all delivery orders must be confirmed by the customer monthly, or the order will not be sent.

Submit the form below

Call us at 781-829-9813 ext. 4 and leave a detailed message.

You will receive either a live or automated call to confirm. If you receive an automated call, simply press 1 to confirm your order. If you receive a voicemail, please return our call to confirm, even if you filled out an email confirmation.

Please provide the following information when confirming:

Patient’s Name
Address
Phone Number
Email Address
Items to be Refilled
Additional Requests or Information

Thank you!

Patient's Name*
Address*
City*
State*
ZIP Code
Phone*
Items to be Refilled*
Additional Request or Information
*
- I understand that in certain circumstances Charm Medical will need to speak with me directly before my product ships.