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TytoCare Order Form
This order will reserve your TytoCare device. Once you have paid, the device will be available for pick up or shipped to your home.
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Email
*
Your email
Name of Parent
*
Your answer
Name of Patient
*
Your answer
Patient Date of Birth
*
MM
/
DD
/
YYYY
Address
*
Your answer
Phone Number
*
Your answer
In order to reserve your device, you will need to go to
https://www.shinepediatrics.com/pay-my-bill/
and put your child's chart number in, and pay the $500 fee. This will cover your device fee and the additional licensing fee to SHINE. (Note this is a one-time fee)
*
Ok Complete!
Required
Would you like to pick up in office or have it shipped to you?
*
In-office
Shipped to my home
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