This site is for US residents only. For Non-US Residents

Immediate Action Required For All Sucraid® Prescriptions

  1. Completion of consent forms is required for shipment.
  2. Please make sure your insurance and financial assistance information is up-to-date.
  3. To coordinate your Sucraid® shipment or for questions, contact SucraidASSIST at 1-800-705-1962 Monday through Friday 8:30 a.m. – 5:30 p.m. (EST).

Click the links for the appropriate forms below:

For Patients:

Patient Consent (18 Years and Older)
Download | Submit Online

Patient Questionnaire
Download

Physician’s Acknowledgment
Download | Submit Online

Updated Limited Supply Letter
Download

For Parents and Guardians:

Patient Consent (Under Age 7)
Submit Online

Patient Consent (Ages 7 to 17)
Submit Online

Minor Assent (Ages 7 to 17) – for Child
Download | Submit Online

(Please Note: Both Ages 7 to 17 forms above must be completed separately.)

QOL Medical, LLC

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