Refill Generator
Provider and patient information
Healthcare Provider Information
Patient Information
Refill Information
There are different types of devices.
Select the type of code displayed on the device screen. *
For “C###”, enter the three digits only.
I understand that any falsification, omission, or unauthorized use of the refill code generator may subject me to civil or criminal liability. A copy of this order will be retained as part of Phothera’s records.