Submit a request

Please choose a request type below

Your email address

Subject

Please provide specific details so that we may provide faster support.

Practice Username or Name of Affiliate(optional)

NPI(optional)

Account Username(optional)

Is this being delivered to a Residence?

You must answer the above question in order for the address fields to be visible

Organization Name (Practice/Hospital)(optional)

First Name(optional)

Last Name(optional)

Address 1(optional)

Address 2(optional)

City(optional)

State Code(optional)

Zip Code (optional)

Number of Tokens Needed

Select the number of tokens needed

# of Tokens Needed

Provide the number of tokens needed

Replacement?

DrFirst has a 90-day limited warranty period on hard tokens. This limited warranty excludes damage or loss.

Replacement Reason(optional)

Provider's Full name(optional)

Please enter the Provider's Full name for the Replacement Token

Provider's NPI(optional)

Please provide the Provider's NPI requesting the Replacement Token

Attachments(optional)

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