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).

To complete forms online and submit electronically, click the appropriate link below:

English Consent Forms

Patient Consent (Under Age 7) – for Parent/Guardian

Patient Consent (Ages 7 to 17) – for Parent/Guardian

Minor Assent (Ages 7 to 17) – for Child
(Please Note: Both Ages 7 to 17 forms above must be completed separately.)

Patient Consent (18 Years and Older)

Physician’s Acknowledgment

Spanish Consent Forms

Patient Consent (Under Age 7) – for Parent/Guardian

Patient Consent (Ages 7 to 17) – for Parent/Guardian

Minor Assent (Ages 7 to 17) – for Child
(Please Note: Both Ages 7 to 17 forms above must be completed separately.)

Patient Consent (18 Years and Older)

Physician’s Acknowledgment

To download consent forms, click the appropriate link below:

This site is for U.S. Residents Only
QOL Medical, LLC

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