Patient Inquiry

By filling out this form, I am acknowledging that I understand that the information entered above may constitute protected health information, and that by submitting this information, I am consenting to allow Diplomat to use the information to facilitate my treatment and care in accordance with Diplomat’s Notice of Privacy Practices, including, but not limited to, verifying prescription coverage, contacting the patient to confirm enrollment information, and obtaining prescription and other relevant health information from the physician.

  •  
  •  
  •  
  •  
  •