­

[Skip to content](/content/pages/submit-rx#MainContent/index.html)

Unlock 15% Off Sitewide!

[Track Order](/content/account/login/index.html) [Have questions? Call Lofta.\\
1-800-698-8000](tel:18006988000)

# Submit Rx

### **Have a digital prescription or a paper prescription that you can scan or photograph?**

**Email it**

[rx@lofta.com](mailto:rx@lofta.com)

**Upload it**

RX Upload
Form Builder

Edit App

Rate Us

(Only you can see this)

Hide

- Edit on Live Site

- Edit in POWR Editor

- View Submissions

Please let us know how we can improve.

Submit

Cancel

Thank you for your feedback!

Close

Show controls

### This plugin is unclaimed. Sign up to activate it!

Sign Up

### Uh oh, your payment didn’t go through!

Update

(Only you can see this)

### Your trial expired. Please select a plan to continue using POWR One

View plans

(Only you can see this)

### Your free trial has ended. Please upgrade or remove paid features to republish your app.

(Only you can see this)

#### You added paid features to your Form Builder.

##### Upgrade your plan to publish Form Builder with paid features.    Remove paid features to publish Form Builder for free.

#### Your submission has been received, but we're still awaiting payment.

[Click to reopen payment window](https://www.powr.io/form-builder/u/00c59e85_1501094192#)

#### Your submission has been received, but we're still awaiting payment.

Done with Payment

[Click to reopen payment window](https://www.powr.io/form-builder/u/00c59e85_1501094192#)

#### Received. Thank you!

Loading form responses...

[View Results](https://www.powr.io/form-builder/u/00c59e85_1501094192#)

**The submission limit has been reached for this form.**

\*Order Number

0 out of 250 characters

\*Prescription Upload

reCAPTCHA

Recaptcha requires verification.

protected by **reCAPTCHA**

Please fill in required fields.

Braintree doesn't recognize these keys.

You've already submitted a response

Please wait for your uploads to finish.

Payments have not been connected for this form. If you're testing this form, you may need to refresh the page.

Whoa! This form has detected unusual activity, which might be spam. Please contact [support](https://powr.support.site/inbox/new) for help if you continue to see this message.

Continue to Payment

This form was created with POWr.
[Create Your Own](https://www.powr.io/plugins/form-builder/standalone?from=form)

SUBMIT

reCAPTCHA

Select all squares with **motorcycles** If there are none, click skip

|     |     |     |     |
| --- | --- | --- | --- |
|  |  |  |  |
|  |  |  |  |
|  |  |  |  |
|  |  |  |  |

Please try again.

Please select all matching images.

Please also check the new images.

Please select around the object, or reload if there are none.

Skip

### **Only have a paper prescription?**

**Fax it**

858-333-3828

**Mail it**

Lofta Rx

9225 Brown Deer Rd

San Diego, CA 92121

### **Have a prescription from your doctor, but don’t have a copy?**

We can help. Call [800-698-8000](tel:18006988000)

- Choosing a selection results in a full page refresh.

​

### LoftaCare

#### LoftaCare Therapy Package

The gold standard in therapy equipment from ResMed all in one complete package.

#### Jump Start Coaching

A personalized call with a Lofta Sleep Coach to ensure your start of therapy was a success.

#### 60-Night Success Guarantee

If you aren't convinced of the transformative effects within the initial 60-nights, we will refund your device purchase.

#### 60-Night Mask Assurance

Free mask returns and exchanges for a full 60-nights to ensure you have the perfect fit.

#### On-Demand Dedicated Support

Your dedicated Lofta Sleep Coach will stay on call to support you at every step of your journey.

#### Connected Care

Lofta can remotely monitor your nightly sleep data and make therapy adjustments to your device accordingly.

#### Daily Reports Through MyAir

Every day, 365 days a year, receive an e-mail in your inbox showing your sleep therapy outcomes.

#### Compliance Reporting

On-demand clinical reports for an in-depth view of your outcomes and to meet compliance requirements.

#### 3-Year Protection Plan

Lofta will replace any defective device for 3-years regardless of length of the factory warranty.

#### Exclusive Discounts

LoftaCare members get exclusive discounts on the CPAP resupply they need.

​

### Telemed Details

This short video call (less than 5 minutes) is required for the independent medical practice to review your medical history and approve the use of a home sleep test. In some cases co-morbidities, underlying conditions or risk factors may be discussed, and the content of this call is at the discretion of the healthcare professional.

​

### WatchPAT One

The easy-to-use, FDA-approved WatchPAT™ One from Itamar Medical can give a full picture of your sleep health in one night.

- The WatchPAT™ One is an FDA and DOT approved portable sleep apnea diagnostic device. Its innovative technology ensures the accurate screening, detection, and follow-up treatment of sleep apnea.
- Accurately measures for sleep apnea based on up to 7 different factors: PAT signal (peripheral arterial tone), heart rate, oximetry (blood oxygen level).
- Measures true sleep time, sleep architecture, and central sleep apnea.
- Validated against standard polysomnography (PSG).
- Download the WatchPAT™ One app on Google Play or Apple App Store for instructions about how to apply the sensors.

​

### SleepImage Ring

The SleepImage Ring is non-invasive, and comes in multiple sizes, it can be a good alternative for those who have encountered difficulties with other types of sleep test.

- The SleepImage Ring is an intuitive and easy-to-use device that calculates cardiopulmonary coupling (CPC) data for comprehensive sleep assessment.
- It measures parameters like pulse rate, heart rate variability, oximetry, sleep architecture, actigraphy, and more.
- The generated report covers sleep opportunity, sleep apnea events, sleep pathology, and overall sleep quality.
- With real-time monitoring, it captures data throughout the night and provides immediate feedback to healthcare practitioners.
- Setting up and running the test is simple with the accompanying app, making it accessible to anyone.

​

shop.app

# shop.app is blocked

This page has been blocked by an extension

- Try disabling your extensions.

ERR\_BLOCKED\_BY\_CLIENT

Reload

This page has been blocked by an extension

lofta.com

# lofta.com is blocked

This page has been blocked by an extension

- Try disabling your extensions.

ERR\_BLOCKED\_BY\_CLIENT

Reload

This page has been blocked by an extension

lofta.com

# lofta.com is blocked

This page has been blocked by an extension

- Try disabling your extensions.

ERR\_BLOCKED\_BY\_CLIENT

Reload

This page has been blocked by an extension

lofta.com

# lofta.com is blocked

This page has been blocked by an extension

- Try disabling your extensions.

ERR\_BLOCKED\_BY\_CLIENT

Reload

This page has been blocked by an extension

Gorgias Shopper Engagement

Gorgias Floating ChatGorgias Floating Chat

Gorgias live chat messengerGorgias Live Chat

You've Got

15% Off

Continue

By submitting this form, you consent to receive informational (e.g., order updates) and/or marketing texts (e.g., cart reminders) from Lofta. [Notice of Financial Incentive (opens in a new tab) (opens in a new tab)](/content/pages/privacy-policy#notice-to-california-residents/index.html) & [Terms of Use. (opens in a new tab)](/content/pages/terms-of-use/index.html)

NO THANKS, I'LL PAY FULL PRICE
