Refit Order Form for Patient Billing

This is an order form for a single pessary & applicator for a patient who needed to be refit for a new size. Reia offers a discounted price of $70.

The patient will be billed directly. Please note that all devices must be shipped to a practitioner. The only patient information collected on this form is their email address for billing purposes.

Devices will ship to your practice once payment is completed.