ellura™ - PATIENT REFERRAL FORM

Complete the information below to start your patient on ellura. A specialist will contact him/her to answer any questions and to assist with ordering.

Healthcare Provider


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Patient Information


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Recommended Supply

ellura supply

PLEASE SELECT RECOMMENDED PATIENT SUPPLY

30 DAY SUPPLY

60 DAY SUPPLY

90 DAY SUPPLY

ONGOING USE – we will discuss with patient based on automatic refill program costs